Inspection Reports for Ml-Op Goddard, LLC
501 EASY STREET, GODDARD, KS, 67052-9235
Back to Facility ProfileInspection Report Summary
The most recent inspection on November 27, 2018, found no deficiencies and confirmed the facility was in compliance with all regulations surveyed. Prior inspections showed a pattern of deficiencies primarily related to resident care, including falls, wound care, and care plan revisions, as well as issues with medication management, infection control, and environmental sanitation. Several complaint investigations substantiated failures in reporting and investigating abuse or neglect, inadequate supervision, and deficiencies in food safety and emergency preparedness. Enforcement actions included denial of payment for new Medicare and Medicaid admissions at times, and one substantiated complaint involved immediate jeopardy due to failure to prevent resident elopement resulting in injury. The facility’s inspection history indicates improvement over time, with multiple revisit surveys confirming correction of prior deficiencies and the most recent survey showing full compliance.
Deficiencies (last 6 years)
Deficiencies (over 6 years)
21.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
262% worse than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
43 residents
Based on a September 2018 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Nov 27, 2018
Visit Reason
An offsite revisit survey was conducted on 11/27/2018 for all previous deficiencies cited on 09/26/2018.
Findings
All deficiencies have been corrected as of the compliance date of 10/19/2018, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Sep 26, 2018
Visit Reason
A Health 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 deficiencies to be a '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 reviewed and accepted, and the facility was found to be in substantial compliance effective 2018-10-19.
Deficiencies (1)
Most serious deficiencies found to be a 'F' level deficiency, widespread, constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lacey Hunter | Licensure Certification & Enforcement Manager | Contact person for questions concerning the information in the letter. |
Inspection Report
Plan of Correction
Deficiencies: 11
Date: Sep 26, 2018
Visit Reason
This Plan of Correction document responds to deficiencies identified during an annual survey and other investigations related to resident incidents, falls, and care plan updates at the facility.
Findings
The facility reported multiple resident incidents including falls and a resident-to-resident altercation, with investigations and interventions implemented. Staff education, monitoring, and audits were planned to ensure compliance and prevention of future incidents. Environmental and infection control improvements were also addressed.
Deficiencies (11)
Resident #40 and #100 resident to resident altercation reported during annual survey.
Resident #4 fall with injury reported during annual survey.
Resident #41 fall with injury reported prior to annual survey.
Resident #44 bruise of unknown origin reported and investigated.
Resident MDS modifications and audits to ensure accuracy.
Care plans updated to reflect interventions to prevent further falls.
Resident discharge summary completion and monitoring.
Fall and injury interventions reviewed and staff educated.
Medication administration monitoring and education for nurses.
Environmental cleaning and maintenance including kitchen and dietary areas.
Laundry area repairs and infection control education and monitoring.
Report Facts
Deficiency tags: 11
Resident IDs referenced: 6
Dates of incidents: Apr 20, 2018
Dates of incidents: Sep 6, 2018
Dates of incidents: Sep 13, 2018
Date of discharge: Jun 20, 2018
Education dates: Oct 16, 2018
Plan of Correction completion date: Oct 19, 2018
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jean Altenor | Administrator | Administrator named as responsible for monitoring and submission of Plan of Correction |
Inspection Report
Complaint Investigation
Census: 43
Deficiencies: 9
Date: Sep 26, 2018
Visit Reason
The inspection was conducted as a Health Resurvey and Complaint Investigation involving allegations of abuse, neglect, and failure to provide planned services to prevent falls.
Complaint Details
The complaint investigation involved allegations of abuse, neglect, exploitation, or mistreatment including failure to report incidents, failure to investigate thoroughly, and failure to prevent accidents.
Findings
The facility failed to report and thoroughly investigate incidents of alleged abuse/neglect involving multiple residents, failed to complete accurate assessments and timely revise care plans, failed to complete medication reconciliation upon discharge, failed to prevent accidents due to inadequate supervision and assistive devices, failed to identify and report medication irregularities, failed to maintain sanitary food preparation and storage conditions, and failed to maintain an effective infection prevention and control program.
Deficiencies (9)
Failure to report 3 incidents of alleged abuse/neglect involving 4 residents to the state agency as required.
Failure to thoroughly investigate 3 incidents of alleged abuse/neglect involving 4 residents, including lack of notarized witness statements and root cause analysis.
Failure to complete accurate MDS assessments for 2 residents related to functional limitation of range of motion.
Failure to timely revise care plans for 4 residents following falls, including failure to document interventions.
Failure to complete medication reconciliation for 1 resident discharged against medical advice.
Failure to prevent accidents for 4 residents due to inadequate supervision and assistive devices, and failure to investigate cause of bruise of unknown origin.
Consultant pharmacist failed to identify and report irregularities including multiple medication refusals and blood pressure readings out of parameters for 3 residents.
Failure to store and prepare food under sanitary conditions including dusty ceiling fan, dirty ventilation units, damaged cutting boards and spatulas, dirty cabinet doors, refrigerator door seals failing, and grime buildup in preparation area.
Failure to maintain an infection prevention and control program including failure to track and trend infections and maintain sanitary laundry facilities with damaged tables and water-damaged ceiling.
Report Facts
Residents involved in abuse/neglect incidents: 4
Residents sampled: 18
Residents reviewed for accidents: 5
Infections documented in July 2018: 6
Infections documented in August 2018: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Administrative Nursing Staff | Verified failure to report abuse incidents and failure to maintain infection control program. |
| Staff A | Administrative Staff | Verified failure to report resident to resident altercation. |
| Staff I | Administrative Nursing Staff | Reviewed medication refusal reports and confirmed physician notifications. |
| Staff J | Consultant Pharmacist | Monthly drug regimen reviewer who failed to identify medication irregularities. |
| Staff K | Housekeeping Staff | Reported laundry facility maintenance issues. |
| Staff L | Maintenance Staff | Confirmed failure to replace laundry tables and repair ceiling. |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Sep 18, 2018
Visit Reason
A revisit survey was conducted on 9/18/18 for all previous deficiencies cited on 6/29/18 to verify correction of cited deficiencies.
Findings
All deficiencies cited in the prior survey have been corrected as of the compliance date of 7/10/18, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiency citation date: Jun 29, 2018
Compliance date: Jul 10, 2018
Inspection Report
Plan of Correction
Deficiencies: 2
Date: Jul 10, 2018
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies cited in a complaint investigation at Medicalodges Goddard.
Complaint Details
This Plan of Correction is linked to a complaint investigation at Medicalodges Goddard dated 06/29/2018.
Findings
The plan addresses deficiencies related to wound monitoring and treatment to prevent pressure ulcers, including staff education, order audits, and ongoing monitoring to ensure compliance.
Deficiencies (2)
Services Provided Meet Professional Standard related to wound monitoring and skin condition assessments
Treatment/Services to Prevent Heal Pressure Ulcers
Report Facts
Complete Date: Jul 10, 2018
Staff Education Date: Jun 28, 2018
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Jun 29, 2018
Visit Reason
An abbreviated survey was conducted to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found serious deficiencies at a level of actual harm that is not immediate jeopardy, specifically related to pressure ulcers (F686). Due to these deficiencies, enforcement remedies including denial of payment for new Medicare and Medicaid admissions were imposed.
Deficiencies (1)
Noncompliance with F686, Pressure Ulcers, indicating avoidable pressure ulcers and inadequate preventive care.
Report Facts
Denial of payment effective date: Jul 26, 2018
Timeframe for substantial compliance: 6
Civil Money Penalty threshold: 10483
Inspection Report
Complaint Investigation
Census: 50
Deficiencies: 2
Date: Jun 29, 2018
Visit Reason
The inspection was conducted as a complaint investigation based on allegations related to failure to follow physician's orders for arterial Doppler studies and wound care for Resident #1's unstageable left foot ulcer.
Complaint Details
The complaint investigations #KS 00130650 and KS 00130687 revealed failures in care related to Resident #1's wound and treatment, including lack of timely notification to physician and failure to follow orders for Doppler studies and wound care. Resident #1 passed away due to infection related to the wound.
Findings
The facility failed to meet professional standards of care by not following physician orders to obtain arterial Doppler studies and timely wound care for Resident #1, who developed an unstageable pressure ulcer that worsened and contributed to the resident's death. The facility also failed to notify the physician timely of the wound's worsening condition and did not send the resident to the wound care center as ordered.
Deficiencies (2)
Failure to follow physician's orders for arterial Doppler studies and wound care for Resident #1's unstageable left foot ulcer.
Failure to provide care consistent with professional standards to prevent and treat pressure ulcers, resulting in an unstageable pressure ulcer and delayed treatment.
Report Facts
Resident census: 50
Pressure ulcer measurements: 1.8
Pressure ulcer measurements: 2.1
Antibiotic treatment duration: 8
Antibiotic treatment duration: 2
Intravenous antibiotic treatment duration: 4
Intravenous antibiotic treatment duration: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse D | Licensed Nurse | Named in failure to complete physician orders and documentation of wound condition on 6/13/2018 |
| Licensed Nurse C | Licensed Nurse | Observed wound worsening, notified APRN, and called attending physician for hospital transfer order |
| Licensed Nurse B | Licensed Nurse | Called VA for update on Resident #1, notified physician and obtained hospital transfer order |
| Physician's APRN | Advanced Practiced Registered Nurse | Provided orders for labs, antibiotics, Doppler studies, and wound care on 6/14/2018 |
Inspection Report
Follow-Up
Deficiencies: 3
Date: Dec 27, 2017
Visit Reason
This revisit inspection was conducted to verify that previously reported deficiencies have been corrected and to document the date such corrective actions were accomplished.
Findings
The report confirms that all previously cited deficiencies identified by regulation numbers 26-41-101 (f)(3), 26-41-104 (d), and 26-41-206 (d) have been corrected as of the revisit date.
Deficiencies (3)
Deficiency related to regulation 26-41-101 (f)(3)
Deficiency related to regulation 26-41-104 (d)
Deficiency related to regulation 26-41-206 (d)
Inspection Report
Complaint Investigation
Census: 18
Deficiencies: 3
Date: Dec 6, 2017
Visit Reason
The inspection was a resurvey of the residential health care facility conducted on 12/4/17, 12/5/17, and 12/6/17, triggered by complaint-related issues including allegations of abuse, neglect, and concerns about disaster preparedness and food safety.
Complaint Details
The complaint investigation found that the administrator failed to report an allegation of potential abuse and/or neglect of resident #322 to the department within 24 hours and failed to complete an investigation to rule out abuse and/or neglect.
Findings
The facility failed to report and investigate an allegation of potential abuse within 24 hours, did not conduct quarterly reviews of the emergency management plan with residents and employees, and failed to ensure food was served at the proper temperature.
Deficiencies (3)
Failure to report and investigate an allegation of potential abuse and/or neglect within 24 hours.
Failure to ensure disaster and emergency preparedness by not conducting quarterly reviews of the emergency management plan with residents and employees.
Failure to ensure food was served to residents at the proper temperature.
Report Facts
Census: 18
Residents sampled: 3
Food temperature: 141.1
Food temperature: 149
Food temperature: 175.6
Food temperature: 174.3
Last recorded food temperature date: May 26, 2014
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Residential care coordinator C | Mentioned in relation to failure to report abuse and failure to measure food temperatures | |
| Certified dietary manager D | Provided information about food preparation and temperature measurements | |
| Certified staff E | Provided the notebook where food temperatures were recorded | |
| Administrator B | Confirmed lack of quarterly emergency management plan reviews |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Dec 5, 2017
Visit Reason
An off-site survey was conducted to address a previously cited deficiency (F280, "D" level) from 11/6/17.
Findings
The deficiency cited on 11/6/17 was corrected effective 11/7/17 as noted in the plan of correction.
Deficiencies (1)
Deficiency F280, cited at level "D" on 11/6/17
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Dec 5, 2017
Visit Reason
This document is a Plan of Correction submitted to address deficiencies identified in a prior inspection and to confirm that all deficiencies have been corrected.
Findings
All deficiencies have been corrected and no new noncompliance was found as of the date of the Plan of Correction.
Deficiencies (1)
All deficiencies have been corrected and no new noncompliance was found.
Report Facts
Complete Date: Dec 5, 2017
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Dec 5, 2017
Visit Reason
A revisit survey was conducted on 12/5/17 to verify correction of all previous deficiencies cited on 10/18/17.
Findings
All previously cited deficiencies have been corrected, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Dec 5, 2017
Visit Reason
A revisit survey was conducted on 12/5/17 for all previous deficiencies cited on 10/18/17.
Findings
All deficiencies have been corrected, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Plan of Correction
Deficiencies: 2
Date: Nov 7, 2017
Visit Reason
The document is a Plan of Correction addressing issues identified in a prior complaint survey (Event ID TJ7011) related to facility compliance.
Findings
The facility plans to adjust its Quality Assurance efforts to maintain substantial compliance, including updating resident care plans based on assessment findings and event investigations, and conducting mandatory staff in-service training to prevent re-occurrence of identified issues.
Deficiencies (2)
Resident #1 care plan updated based on assessment findings and event investigation to prevent re-occurrence; all residents checked for elopement risk and care plans reviewed for accuracy.
Past noncompliance noted with no Plan of Correction required.
Report Facts
Complete Date: Nov 7, 2017
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact for Plan of Correction assistance | |
| Frank Dungan | Administrator | Submitted the Plan of Correction |
Inspection Report
Abbreviated Survey
Deficiencies: 2
Date: Nov 6, 2017
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 deficiencies to be Immediate Jeopardy, Past Non-compliance to resident health or safety for F323, and additionally F280 was cited at a 'D' level. The facility submitted a plan of correction for F280 which was accepted, resulting in substantial compliance for that deficiency.
Deficiencies (2)
Immediate Jeopardy, Past Non-compliance to resident health or safety for F323
F280 deficiency
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Caryl Gill | Complaint Coordinator | Named as contact and signer of the report letter |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Nov 6, 2017
Visit Reason
An abbreviated survey was conducted to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found that the facility was not in substantial compliance with participation requirements and that conditions constituted Immediate Jeopardy and Past Non-compliance to resident health or safety for F323, "J" CFR 483.25(d)(1)(2)(n)(1)-(3). Enforcement remedies will be imposed without opportunity for correction.
Deficiencies (1)
Facility conditions constituted Immediate Jeopardy and Past Non-compliance to resident health or safety for F323, "J" CFR 483.25(d)(1)(2)(n)(1)-(3).
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Frank Dungan | Administrator | Named as facility administrator in the report. |
| Caryl Gill | Complaint Coordinator | Contact person for questions concerning the instructions contained in the letter. |
Inspection Report
Complaint Investigation
Census: 42
Deficiencies: 2
Date: Nov 6, 2017
Visit Reason
The inspection was a partial extended survey and complaint investigation related to resident elopement and care plan revision.
Complaint Details
Complaint investigation #KS00122629 regarding resident elopement and care plan deficiencies. The complaint was substantiated with findings of immediate jeopardy due to failure to implement elopement risk interventions.
Findings
The facility failed to implement interventions to reduce the risk of elopement for one resident assessed as high risk, resulting in the resident eloping from the facility, sustaining injuries, and losing corrective lenses. The facility also failed to identify the resident as an elopement risk prior to the incident and did not have effective care plan interventions in place until after the elopement occurred.
Deficiencies (2)
Failed to implement intervention to reduce risk for elopement for resident #1 after assessment of high risk on 10/15/17.
Failed to identify resident #1 as an elopement risk and implement interventions to reduce risk, resulting in immediate jeopardy when resident eloped and sustained injuries.
Report Facts
Facility census: 42
Resident elopement distance: 862
Resident elopement dates: Oct 15, 2017
Resident elopement dates: Oct 20, 2017
Resident elopement dates: Oct 21, 2017
Resident BIMS scores: 10
Resident BIMS scores: 14
Resident elopement risk scores: 3
Resident elopement risk scores: 14
Resident elopement risk scores: 29
Outdoor temperature: 72
Outdoor temperature: 71
Outdoor temperature: 69
Wind speed: 31
Speed limit near elopement location: 50
Speed limit near elopement location: 60
Speed limit near resident found location: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative nurse B | Administrative Nurse | Confirmed resident #1 was identified as elopement risk after 10/15/17 and failure to implement care plan interventions. |
| Licensed nurse C | Licensed Nurse | Identified resident missing, involved in elopement response and investigation. |
| Direct care staff D | Direct Care Staff | Located resident after elopement in open field and returned resident to facility. |
| Direct care staff G | Direct Care Staff | Reported resident was not identified as elopement risk before 10/20/17. |
| Administrative staff A | Administrative Staff | Conducted door and alarm system inspection after elopement and interviewed resident. |
Inspection Report
Plan of Correction
Deficiencies: 2
Date: Oct 19, 2017
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified in a complaint investigation (Medicalodges Goddard Complaint 101817).
Complaint Details
This Plan of Correction addresses deficiencies identified during a complaint investigation related to notification failures and clinical monitoring.
Findings
The facility acknowledged issues related to notification of changes in resident conditions and lab results, and outlined corrective actions including staff in-service training, daily clinical reviews, and ongoing monitoring to ensure compliance.
Deficiencies (2)
Failure to notify physician and family of change in resident condition and critical lab values in a timely manner.
Inadequate assessment and follow-up on resident conditions and lab results.
Report Facts
Date for substantial compliance: Oct 18, 2017
Date of staff training completion: Oct 11, 2017
Date of audit completion: Oct 13, 2017
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Oct 18, 2017
Visit Reason
An abbreviated survey was conducted by the Kansas Department for Aging and Disability Services to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies to be F309, "G", at a level of actual harm that is not immediate jeopardy. Based on these deficiencies, the facility will not be given an opportunity to correct before enforcement remedies are imposed, including denial of payment for new Medicare and Medicaid admissions effective November 7, 2017.
Deficiencies (1)
Deficiency F309, "G", at a level of actual harm that is not immediate jeopardy
Report Facts
Denial of payment effective date: Nov 7, 2017
Compliance deadline: Apr 18, 2018
Civil Money Penalty minimum amount: 5000
IDR submission timeframe: 10
Hearing request timeframe: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Frank Dungan | Administrator | Facility administrator named in the report |
| Caryl Gill | Enforcement Coordinator | Named as contact for questions regarding the enforcement action |
| Lisa Hauptman | CMS Regional Office Contact | Contact person for questions regarding the matter |
Inspection Report
Complaint Investigation
Census: 44
Deficiencies: 2
Date: Oct 18, 2017
Visit Reason
Complaint investigation #121644 regarding failure to notify physician, resident, and/or resident representative of changes in condition and critical lab values for two sampled residents.
Complaint Details
Complaint investigation #121644 focused on failure to notify physician, resident, and/or resident representative of changes in condition and critical lab values for 2 sampled residents.
Findings
The facility failed to notify the physician, resident, and/or resident representative of changes in condition and critical lab values for 2 sampled residents. Resident #1 had changes in condition over 8 days without nursing assessments or vital sign monitoring, including critical lab values and edema. Resident #2 had critical lab values not reported to the physician and lacked nurse assessments. The facility also failed to ensure proper monitoring and assessment related to dialysis care, fluid restrictions, and response to critical lab results.
Deficiencies (2)
Failure to notify physician, resident, and/or resident representative of changes in condition and critical lab values for 2 sampled residents.
Failure to provide nurse assessments following changes in condition, monitoring of health conditions, and timely response to critical laboratory results for 2 sampled residents.
Report Facts
Resident census: 44
Critical Troponin level: 15.47
BNP level: 2510
WBC count: 15.5
Creatinine level: 7.11
Creatinine level: 9.84
Fluid restriction: 1200
Resident weight: 225.6
Weight change percentage: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse H | Licensed Nurse | Received critical lab results for Resident #1 and contacted on-call physician extender |
| Physician Extender J | Physician Extender | Provided orders after Nurse H called regarding critical lab results |
| Licensed Nurse D | Licensed Nurse | Received critical lab calls for Resident #2 and involved in care |
| Licensed Nurse K | Licensed Nurse | Responded to changes in Resident #1 condition and involved in care |
| Direct Care Staff E | Direct Care Staff | Reported changes in Resident #1 condition to nursing staff |
| Direct Care Staff M | Direct Care Staff | Reported gradual decline in Resident #1 condition to nursing staff |
| Direct Care Staff N | Direct Care Staff | Noted changes in Resident #1 condition and reported to nursing staff |
| Administrative Nurse B | Administrative Nurse | Provided expectations for nurse assessments and notification of changes |
| Licensed Nurse C | Licensed Nurse | Monitored Resident #1 condition and involved in care |
| Administrative Staff A | Administrative Staff | Provided information on dialysis vital signs and policies |
Inspection Report
Follow-Up
Deficiencies: 3
Date: Apr 30, 2017
Visit Reason
This post-certification revisit was conducted to verify that previously reported deficiencies on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
The report confirms that all identified deficiencies with regulation numbers 483.25(d)(1)(2)(n)(1)-(3), 483.60(i)(1)-(3), and 483.90(i)(5) were corrected as of the revisit date.
Deficiencies (3)
Deficiency related to regulation 483.25(d)(1)(2)(n)(1)-(3)
Deficiency related to regulation 483.60(i)(1)-(3)
Deficiency related to regulation 483.90(i)(5)
Inspection Report
Plan of Correction
Deficiencies: 3
Date: Apr 5, 2017
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited in the Medicalodges Goddard inspection report dated 04/05/2017.
Findings
The facility identified issues related to fall interventions, food storage and labeling, and kitchen floor tile conditions. Corrective actions include revising care plans, staff education, implementation of audit systems, and repair of kitchen floor tiles to achieve substantial compliance by 04/30/2017.
Deficiencies (3)
Resident #31 and #53 care plans for fall interventions were reviewed and revised to reflect appropriate interventions related to falls.
Staff in-service including proper storage and labeling of food.
Floor tiles in the kitchen were assessed and determined repairable by replacing damaged and stained tiles.
Report Facts
Completion date for Plan of Correction: Apr 30, 2017
Date of staff education on fall management: Mar 29, 2017
Date of staff in-service on food storage and labeling: Apr 18, 2017
Inspection Report
Complaint Investigation
Census: 50
Deficiencies: 3
Date: Apr 5, 2017
Visit Reason
The inspection was conducted as a Health Resurvey and Complaint Investigation focusing on falls and food safety concerns at Medicalodges Goddard.
Complaint Details
The visit was triggered by complaints related to falls and food safety. The facility failed to properly investigate falls and update care plans for residents #53 and #31. Food safety issues included expired and undated food items in refrigerators accessible to residents. The kitchen floor was damaged and not properly cleanable.
Findings
The facility failed to identify causal factors and plan appropriate interventions to prevent further falls for two residents reviewed. Additionally, the facility failed to maintain sanitary food storage practices by not labeling and dating food items and discarding expired food. The kitchen floor was also found to be damaged and not cleanable, posing a sanitary risk.
Deficiencies (3)
Failed to identify causal factors and plan appropriate interventions to prevent further falls for residents #53 and #31.
Failed to maintain, store and serve food under sanitary conditions by failing to mark and date food items and discard expired food.
Failed to provide a safe, functional, sanitary, and comfortable environment; kitchen floor was damaged, stained, and not cleanable.
Report Facts
Census: 50
Fall risk score: 15
Fall risk score: 16
Fall risk score: 21
Expired food date: 2017
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Direct Care Staff | Reported resident #53 wanted to transfer self and refused assistance |
| Staff E | Direct Care Staff | Assisted resident #53 with transfers and toileting; reported resident sometimes used call light |
| Staff F | Direct Care Staff | Reported resident #53 required 1-2 staff assistance with toileting |
| Staff G | Direct Care Staff | Reported resident #53 would get up and try to go to bathroom alone and did not use call light |
| Nurse H | Licensed Nurse | Reported resident #53 recently went on hospice and had 2 recent falls |
| Nurse J | Licensed Nurse | Reported resident #31 sometimes used call light and was cognitively alert |
| Staff K | Administrative Nursing Staff | Reported nutrition room door remained unlocked and residents had access to refrigerators |
| Staff C | Maintenance Staff | Reported kitchen floors were old, stained, broken around drains, and not cleanable |
| Staff B | Dietary Staff | Reported attempts to clean kitchen floors but floors remained stained and damaged |
| Administrative Staff A | Administrator | Acknowledged poor condition of kitchen floors and discussed with home office |
Inspection Report
Deficiencies: 1
Date: Apr 5, 2017
Visit Reason
A Health 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 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, resulting in a finding of substantial compliance effective April 30, 2017.
Deficiencies (1)
Most serious deficiencies were 'F' level, widespread, constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure Certification & Enforcement Manager | Signed letter regarding survey findings and plan of correction acceptance. |
Inspection Report
Life Safety
Deficiencies: 1
Date: Sep 8, 2016
Visit Reason
A Life Safety Code survey was conducted by the State Fire Marshal's Office to determine if the facility was in compliance with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies to be at '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.
Deficiencies (1)
Most serious deficiencies found at 'F' level with no harm but potential for more than minimal harm that is not immediate jeopardy.
Report Facts
Days to submit plan of correction: 10
Effective date for denial of payments: Dec 8, 2016
Provider agreement termination date: Mar 8, 2017
IDR request timeframe: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure Certification & Enforcement Manager | Signed the report and mentioned in relation to enforcement and certification. |
| Brenda McNorton | Director of Fire Prevention Division | Contact person for Informal Dispute Resolution process. |
Inspection Report
Follow-Up
Deficiencies: 1
Date: May 31, 2016
Visit Reason
This visit was a post-certification revisit to verify that previously reported deficiencies had been corrected as indicated on the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
The report confirms that the previously cited deficiencies, specifically under regulation 483.13(c)(1)(ii)-(iii), (c)(2)-(4), were corrected as of the revisit date.
Deficiencies (1)
Deficiency related to regulation 483.13(c)(1)(ii)-(iii), (c)(2)-(4)
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: May 19, 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 indicating 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 effective May 31, 2016.
Deficiencies (1)
Most serious deficiency found was a 'D' level deficiency constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Caryl Gill | Complaint Coordinator | Named as the contact person and signatory of the report letter. |
Inspection Report
Plan of Correction
Deficiencies: 2
Date: May 19, 2016
Visit Reason
The document is a Plan of Correction submitted in response to deficiencies identified in a complaint investigation survey conducted on May 19, 2016.
Complaint Details
This Plan of Correction is in response to a complaint investigation identified as ML Goddard complaint dated 05/19/2016.
Findings
The facility plans to adjust its quality assurance efforts to maintain substantial compliance and will conduct staff in-service training on abuse, neglect, and misappropriation of property by May 31, 2016, with ongoing annual training and monitoring by the administrator.
Deficiencies (2)
Failure to maintain substantial compliance with participation requirements as noted in the complaint survey.
Need for staff training on abuse, neglect, and misappropriation of property.
Report Facts
Complete Date for corrective actions: May 31, 2016
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Frank Dungan | Administrator | Submitted the Plan of Correction |
| Shirley Boltz | Contact person for Plan of Correction assistance |
Inspection Report
Complaint Investigation
Census: 55
Deficiencies: 1
Date: May 19, 2016
Visit Reason
The inspection was conducted as a complaint investigation related to allegations of misappropriation/exploitation of resident property.
Complaint Details
The complaint investigation involved allegations of misappropriation/exploitation of resident #1's property (cell phone). The allegation was substantiated by evidence that the facility did not report the incident to the state agency as required.
Findings
The facility failed to report an allegation of misappropriation/exploitation of a resident's cell phone to the state agency and did not have evidence of a thorough investigation for one sampled resident. Interviews and record reviews confirmed the allegation was not reported as required by policy.
Deficiencies (1)
Failure to report an allegation of misappropriation/exploitation of resident property and lack of evidence of investigation for one resident.
Report Facts
Facility census: 55
Residents sampled for missing property: 3
BIMS score: 15
Phone bill amount: 100
Investigation reporting timeframe: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative staff K | Reported the allegation of misappropriation but did not report it to the state agency. | |
| Administrative nurse K | Confirmed the report of the allegation and did not report it to the state agency. | |
| Administrative staff L | Provided typed notes about the phone call regarding the allegation. | |
| Direct care staff A | Interviewed and reported no knowledge of misuse of the resident's phone. | |
| Direct care staff C | Interviewed and reported hearing about the family taking the phone but no knowledge of misuse. | |
| Licensed nurse H | Interviewed and reported no knowledge of misuse of the resident's phone. |
Inspection Report
Follow-Up
Deficiencies: 4
Date: Apr 29, 2016
Visit Reason
This post-certification revisit was conducted to verify that previously reported deficiencies on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
All previously cited deficiencies identified by regulation numbers 483.12(a)(3), 483.12(a)(4)-(6), 483.25(d), and 483.25(k) were corrected as of the revisit date.
Deficiencies (4)
Deficiency related to regulation 483.12(a)(3)
Deficiency related to regulation 483.12(a)(4)-(6)
Deficiency related to regulation 483.25(d)
Deficiency related to regulation 483.25(k)
Inspection Report
Complaint Investigation
Census: 50
Deficiencies: 4
Date: Apr 22, 2016
Visit Reason
The inspection was conducted as a complaint investigation (#93102) focusing on concerns related to involuntary discharge procedures, catheter care, and oxygen therapy management at the facility.
Complaint Details
Complaint investigation #93102 focused on issues including involuntary discharge procedures, catheter care, and oxygen therapy management.
Findings
The facility failed to document physician rationale for involuntary discharge, provide proper discharge notice, maintain catheter care standards including keeping tubing off the floor and proper perineal care, and ensure continuous oxygen therapy with proper equipment maintenance and monitoring for residents requiring oxygen.
Deficiencies (4)
Failed to have documentation of the rationale for involuntary discharge from the physician prior to serving a discharge notice to a resident.
Failed to provide proper written notice of transfer/discharge including clinical reason and location to resident and family.
Failed to provide appropriate catheter care by not keeping catheter tubing and collection bag off the floor and failure to provide perineal care using a separate cloth to clean the catheter.
Failed to provide adequate monitoring and maintenance of oxygen therapy including ensuring continuous oxygen use, proper flow rate, and cleaning/replacing tubing and filters as scheduled.
Report Facts
Residents sampled for catheter care: 3
Residents reviewed for oxygen use: 3
Resident census: 50
Oxygen tubing change frequency: 7
Oxygen flow rate: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative staff B | Interviewed regarding discharge procedures and documentation. | |
| Administrative nursing staff G | Interviewed regarding discharge procedures, catheter care expectations, and oxygen therapy maintenance. | |
| Social service staff A | Interviewed regarding resident discharge planning and communication with ombudsman. | |
| Direct care staff D | Observed providing catheter care with noted deficiencies. | |
| Direct care staff E | Interviewed about catheter care procedures. | |
| Direct care staff H | Interviewed about oxygen therapy care and tubing changes. | |
| Licensed nursing staff F | Interviewed about catheter care expectations and oxygen therapy supervision. | |
| Direct care staff J | Interviewed about oxygen tubing maintenance. | |
| Housekeeping staff O | Interviewed about cleaning of oxygen concentrator filters. | |
| Licensed nursing staff I | Interviewed regarding resident oxygen use and flow rate. | |
| Direct care staff L | Interviewed about oxygen therapy care requirements. |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Apr 22, 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 deficiencies to be 'D' level deficiencies that constitute 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 effective April 29, 2016.
Deficiencies (1)
Deficiencies cited at 'D' level constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Report Facts
Deficiency severity level: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Caryl Gill | Complaint Coordinator | Named in relation to the survey findings and correspondence |
Inspection Report
Follow-Up
Deficiencies: 5
Date: Oct 22, 2015
Visit Reason
This visit was conducted as a post-certification revisit to verify that previously identified deficiencies had been corrected.
Findings
The report documents that all previously cited deficiencies were corrected as of the revisit date, with corrections completed for multiple regulatory items.
Deficiencies (5)
Deficiency identified under regulation 483.15(h)(2)
Deficiency identified under regulation 483.25(h)
Deficiency identified under regulation 483.60(a),(b)
Deficiency identified under regulation 483.60(b),(d),(e)
Deficiency identified under regulation 483.65
Report Facts
Deficiencies corrected: 5
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Oct 22, 2015
Visit Reason
This revisit report documents the correction of deficiencies previously reported during an earlier survey and verifies the date such corrective actions were accomplished.
Findings
The report confirms that previously identified deficiencies, specifically related to regulation 28-39-158(a), were corrected as of the revisit date.
Deficiencies (1)
Deficiency related to regulation 28-39-158(a)
Report Facts
Deficiency correction date: Oct 22, 2015
Inspection Report
Re-Inspection
Deficiencies: 4
Date: Oct 21, 2015
Visit Reason
This report documents a revisit inspection to verify that previously reported deficiencies have been corrected and to confirm the dates such corrective actions were accomplished.
Findings
The revisit inspection confirmed that all previously cited deficiencies identified by regulation numbers 28-39-158(a), 26-41-205 (d)(1-2), 26-41-205 (e)(f), and 26-41-205 (h) were corrected as of 10/21/2015.
Deficiencies (4)
Deficiency related to regulation 28-39-158(a)
Deficiency related to regulation 26-41-205 (d)(1-2)
Deficiency related to regulation 26-41-205 (e)(f)
Deficiency related to regulation 26-41-205 (h)
Inspection Report
Plan of Correction
Deficiencies: 4
Date: Sep 29, 2015
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a prior survey.
Findings
The facility developed and implemented corrective actions addressing deficiencies related to dietary management, medication administration including Digoxin pulse monitoring, verbal order signatures, and insulin storage and disposal. The plan includes monitoring and auditing processes to ensure continued compliance.
Deficiencies (4)
Dietary manager enrolled in dietary classes and will test for CDM certification by December 2015.
Pulse was added to resident #3 Digoxin medication records; all Digoxin recipients reviewed and updated.
Resident #1 and #2 verbal orders have been signed; all verbal orders reviewed for signatures.
Certified Medication Aides in-serviced on proper insulin storage and discard instructions.
Report Facts
Complete dates for corrective actions: Oct 2, 2015
Complete dates for corrective actions: Oct 21, 2015
Complete dates for corrective actions: Sep 29, 2015
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Frank Dungan | Administrator | Submitted the Plan of Correction |
Inspection Report
Enforcement
Deficiencies: 1
Date: Sep 22, 2015
Visit Reason
A Health 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 deficiencies to be 'E' level deficiencies, pattern, constituting 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 effective October 22, 2015.
Deficiencies (1)
Deficiencies cited at 'E' level, pattern, constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Named as Enforcement Coordinator in relation to the enforcement action and report. |
Inspection Report
Re-Inspection
Census: 54
Deficiencies: 5
Date: Sep 22, 2015
Visit Reason
The inspection was a Health Resurvey to assess compliance with previously cited deficiencies related to housekeeping, maintenance, safety hazards, pharmaceutical services, medication management, infection control, and other regulatory requirements.
Findings
The facility failed to maintain a sanitary and comfortable environment due to housekeeping and maintenance deficiencies, failed to keep hazardous chemicals out of residents' reach, did not adequately monitor exit door alarms, failed to provide routine medications timely for a resident, had expired medication in the medication cart, and failed to use proper clean technique during wound dressing changes.
Deficiencies (5)
Failed to provide housekeeping and maintenance services necessary to maintain a sanitary and comfortable interior, including scuff marks, peeling wallpaper, and lack of preventive maintenance plan.
Failed to keep hazardous chemicals out of residents' reach, monitor exit door alarms adequately, and maintain a hallway free of clutter creating accident hazards.
Failed to provide pharmaceutical services ensuring routine medications were administered timely to resident #75.
Failed to adequately monitor medications for outdates; expired Humalog insulin pen found in medication cart.
Failed to use proper clean technique during wound dressing change for resident #39, including not changing gloves after touching potentially contaminated surfaces.
Report Facts
Census: 54
Residents affected: 11
Residents cognitively impaired: 3
Residents reviewed for medications: 22
Residents reviewed for wound care: 3
Expired medication found: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff G | Maintenance Staff | Reported knowledge of maintenance issues and lack of preventive maintenance plan |
| Staff O | Housekeeping Staff | Reported inability to clean stained tile and verified chemical storage requirements |
| Staff M | Direct Care Staff | Verified proper chemical storage requirements |
| Staff N | Housekeeping Staff | Verified proper chemical storage requirements |
| Staff B | Administrative Nursing Staff | Reported chemical storage policies and medication ordering procedures |
| Staff P | Direct Care Staff | Observed administering medications and handling door alarms |
| Staff H | Licensed Nurse | Handled door alarms and medication administration |
| Staff S | Direct Care Staff | Observed silencing door alarms without proper checks |
| Staff T | Direct Care Staff | Reported use of hallway for equipment storage |
| Staff Q | Licensed Nurse | Reported medication changes and resident behavior |
| Staff K | Licensed Nurse | Reported medication ordering process and wound care technique |
| Staff R | Direct Care Staff | Reported resident emotional status |
| Staff U | Licensed Nurse | Verified expired insulin pen should have been discarded |
Inspection Report
Re-Inspection
Census: 19
Deficiencies: 4
Date: Sep 22, 2015
Visit Reason
The inspection was a Health Licensure Resurvey to assess compliance with state regulations for the nursing facility.
Findings
The facility failed to assign overall supervisory responsibility for dietetic services to a full-time licensed dietitian or certified dietary manager. The facility also failed to assess resident #3's pulse rate daily prior to Digoxin administration, failed to ensure timely signatures on verbal medication orders for residents #1 and #2, and failed to properly label and store an insulin pen for resident #1 according to medication storage policies.
Deficiencies (4)
Failed to assign overall supervisory responsibility for dietetic services to a full-time licensed dietitian or certified dietary manager.
Failed to assess resident #3's pulse rate prior to daily administration of Digoxin as required.
Failed to ensure medical care provider signed all verbal medication orders within seven working days for residents #1 and #2.
Failed to label and store an insulin pen for resident #1 in accordance with medication storage policy to ensure administration within recommended expiration date.
Report Facts
Census: 19
Residents sampled: 3
Working days late for verbal order signatures: 70
Working days late for verbal order signatures: 85
Working days late for verbal order signatures: 86
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Dietary Staff | Dietary staff who supervised lunch meal service but was not certified as a CDM |
| Administrative Staff D | Administrative Staff | Confirmed staff C's enrollment in dietary manager training and facility policy absence on CDM staffing |
| Direct Care Staff B | Direct Care Staff | Confirmed lack of pulse assessment prior to Digoxin administration and lack of insulin pen labeling |
| Licensed Nurse A | Licensed Nurse | Unaware of missing pulse assessments and verbal order signature requirements; confirmed insulin pen labeling policy |
Inspection Report
Follow-Up
Deficiencies: 1
Date: Apr 24, 2015
Visit Reason
This is a post-certification revisit conducted to verify that previously cited deficiencies have been corrected as documented on the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
The report confirms that the deficiency identified under regulation 483.25(h) was corrected as of 04/24/2015. No other deficiencies or uncorrected issues are noted.
Deficiencies (1)
Deficiency under regulation 483.25(h) previously cited
Report Facts
Deficiency correction date: Apr 24, 2015
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Apr 15, 2015
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified in a complaint investigation survey (Medicalodges Goddard 041415 Complaint).
Complaint Details
This Plan of Correction addresses deficiencies identified in a complaint investigation survey.
Findings
The facility plans to adjust its Quality Assurance efforts to maintain substantial compliance. Specific corrective actions include medication storage policy review and monitoring, and fall investigation and care plan review with staff education and root cause analysis.
Deficiencies (1)
Issues related to medication storage and fall investigations.
Report Facts
Residents potentially affected: 12
Complete date: Apr 24, 2015
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Frank Dungan | Administrator | Submitted the Plan of Correction |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Apr 14, 2015
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 an 'E' level deficiency indicating 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 effective April 24, 2015.
Deficiencies (1)
Most serious deficiency was an 'E' level deficiency indicating no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Jane Kennedy | Complaint Coordinator | Named as the contact person for the survey and plan of correction acceptance. |
Inspection Report
Complaint Investigation
Census: 56
Deficiencies: 2
Date: Apr 14, 2015
Visit Reason
The inspection was conducted as a complaint survey involving multiple complaint surveys #82897, #84698, and #77494, focusing on falls and medication storage safety.
Complaint Details
The complaint surveys #82897, #84698, and #77494 triggered the investigation. The facility failed to determine the root cause of falls and identify if residents had adequate supervision. The facility also failed to implement new interventions after each fall for resident #5.
Findings
The facility failed to thoroughly investigate falls to determine root causes and revise care plans for residents #2 and #5. The facility also failed to safely store medications to prevent accidents for 12 cognitively impaired and independently mobile residents. Numerous fall incidents were documented with inadequate investigation and lack of new interventions after falls.
Deficiencies (2)
Failed to thoroughly investigate falls to determine root cause and revise care plans for residents #2 and #5.
Failed to safely store medications to prevent accidents for 12 cognitively impaired and independently mobile residents.
Report Facts
Facility census: 56
Residents in sample: 6
Residents with medication storage issue: 12
Fall risk scores: 16
Fall risk scores: 24
Number of falls: 4
Blood pressure: 220
Laceration size: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative nurse A | Administrative Nursing Staff | Interviewed regarding fall investigations and interventions |
| Direct care staff A | Direct Care Staff | Confirmed medication cart was unlocked and unattended |
| Direct care staff B | Licensed Nursing Staff | Interviewed regarding resident #2 and #5 fall risks and interventions |
| Direct care staff C | Direct Care Staff | Interviewed regarding resident #2 fall risk and care |
| Direct care staff D | Direct Care Staff | Interviewed regarding resident #2 fall risk and care |
| Direct care staff F | Direct Care Staff | Interviewed regarding resident #5 fall risk and care |
| Licensed nursing staff E | Licensed Nursing Staff | Observed with resident #5 at nurse's station |
| Physician extender G | Physician Extender | Interviewed regarding resident #5 care and fall prevention |
Inspection Report
Life Safety
Deficiencies: 1
Date: Oct 15, 2014
Visit Reason
A Life Safety Code survey was conducted by the State Fire Marshal's Office to determine if the facility was in 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 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.
Deficiencies (1)
Most serious deficiency found to be an "F" level deficiency, widespread, with no harm but potential for more than minimal harm that is not immediate jeopardy.
Report Facts
Days to submit plan of correction: 10
Effective date for denial of payments: Jan 15, 2015
Provider agreement termination date: Apr 15, 2015
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed the enforcement letter and coordinated the survey. |
| Brenda McNorton | Director of Fire Prevention Division | Contact person for Informal Dispute Resolution process. |
Inspection Report
Re-Inspection
Deficiencies: 2
Date: Jun 16, 2014
Visit Reason
This is a revisit report to verify that previously reported deficiencies have been corrected and to document the dates such corrective actions were accomplished.
Findings
The report confirms that deficiencies identified in prior inspections, specifically those referenced by regulation numbers 26-41-204 (c) and 26-41-104 (d), were corrected as of 06/16/2014.
Deficiencies (2)
Deficiency related to regulation 26-41-204 (c)
Deficiency related to regulation 26-41-104 (d)
Report Facts
Correction completion date: Jun 16, 2014
Follow-up survey completion date: May 29, 2014
Inspection Report
Follow-Up
Deficiencies: 6
Date: Jun 16, 2014
Visit Reason
This is a post-certification revisit to verify that previously reported deficiencies have been corrected as per the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
The report confirms that all previously cited deficiencies identified by their regulation numbers have been corrected as of the revisit date.
Deficiencies (6)
Deficiency related to regulation 483.20(d), 483.20(k)(1)
Deficiency related to regulation 483.20(d)(3), 483.10(k)(2)
Deficiency related to regulation 483.25
Deficiency related to regulation 483.25(h)
Deficiency related to regulation 483.25(l)
Deficiency related to regulation 483.60(a),(b)
Report Facts
Deficiencies corrected: 6
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Jun 16, 2014
Visit Reason
This revisit report documents the correction of deficiencies previously reported during a prior survey, verifying that corrective actions have been accomplished.
Findings
The report confirms that the previously cited deficiency identified by regulation 26-40-305 (c)(1)(2) with ID prefix S1354 was corrected as of 06/16/2014.
Deficiencies (1)
Deficiency related to regulation 26-40-305 (c)(1)(2)
Report Facts
Deficiencies corrected: 1
Inspection Report
Plan of Correction
Deficiencies: 1
Date: May 29, 2014
Visit Reason
A Health 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 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 and the plan.
Deficiencies (1)
Most serious deficiency found was an 'F' level deficiency, widespread, constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed the letter and responsible for enforcement coordination. |
Inspection Report
Re-Inspection
Census: 54
Deficiencies: 6
Date: May 29, 2014
Visit Reason
The inspection was a Health Resurvey to assess compliance with previously cited deficiencies and overall facility regulatory requirements.
Findings
The facility failed to develop comprehensive care plans addressing residents' specific needs, failed to revise care plans after falls, failed to monitor and respond to constipation leading to fecal impaction, failed to ensure adequate supervision and assistive devices to prevent falls, failed to monitor PRN medications for effectiveness, and lacked a pharmaceutical system to ensure proper timing of medication administration.
Deficiencies (6)
Failed to develop a comprehensive care plan addressing history of constipation for a resident to prevent fecal impaction.
Failed to revise care plan after a fall with interventions to prevent further accidents for a resident.
Failed to provide care and services to maintain highest practicable well-being by not monitoring and responding to constipation leading to fecal impaction.
Failed to ensure resident environment free of accident hazards and provide adequate supervision and assistive devices to prevent falls.
Failed to ensure drug regimen free from unnecessary drugs by not monitoring effectiveness of PRN medications for constipation.
Failed to provide pharmaceutical services assuring accurate medication administration times to prevent doses being given too close together.
Report Facts
Facility census: 54
Sample size: 18
Fall risk scores: 10
Fall risk scores: 18
Fall risk scores: 20
Fall risk scores: 18
BIMS score: 15
BIMS score: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative nurse A | Stated care plan should have addressed constipation comprehensively and acknowledged ongoing issues with PRN follow-up | |
| Administrative nurse B | Reported expectations for care plan revisions after falls and identified missing interventions on new care plan | |
| Direct care staff C | Reported resident behaviors related to anxiety and falls, and described supervision challenges | |
| Direct care staff G | Reported resident falls due to anxiety behaviors and ability to raise recliner chair | |
| Direct care staff E | Reported resident had gray tray on wheelchair for personal items, unaware it was for safety | |
| Licensed staff F | Reported family brought gray tray for personal items, unaware it was for safety | |
| Administrative Nurse A | Explained medication administration time frames and issues with doses given too close together |
Inspection Report
Re-Inspection
Census: 16
Deficiencies: 2
Date: May 29, 2014
Visit Reason
This inspection was a licensure resurvey of an Assisted Living/Residential Healthcare facility to assess compliance with health care services and emergency preparedness regulations.
Findings
The facility failed to ensure that personal care was provided only by certified nursing staff employed by the facility, a home health agency, or hospice, as one resident received personal care from a family-employed sitter. Additionally, the facility failed to conduct and document an annual emergency drill involving staff and residents that included evacuation to a secure location.
Deficiencies (2)
Failure to ensure personal care was provided by certified nursing staff employed by the facility, home health agency, or hospice.
Failure to conduct and document an annual emergency drill with staff and residents including evacuation to a secure location.
Report Facts
Facility census: 16
Sample size: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative nurse A | Interviewed regarding personal care provision and emergency drill documentation |
Inspection Report
Plan of Correction
Deficiencies: 2
Date: May 23, 2014
Visit Reason
The plan of correction addresses deficiencies identified in a prior inspection, including termination of a private caregiver arrangement and conducting a disaster drill after missing documentation from the previous year.
Findings
The facility terminated a private caregiver arrangement to ensure all direct care staff are certified and employed by the facility or authorized agencies. Additionally, the facility conducted a disaster drill on 5/23/2014 after missing documentation from 2013, with plans to ensure ongoing compliance and documentation.
Deficiencies (2)
Termination of private caregiver arrangement; ensuring all certified staff are employed by the facility or authorized agencies
Failure to locate annual disaster drill documentation from 2013; conducted disaster drill on 5/23/14
Report Facts
Date of disaster drill: May 23, 2014
Plan of correction completion date: Jun 16, 2014
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Frank Dungan | Administrator | Submitted the plan of correction |
Inspection Report
Follow-Up
Deficiencies: 4
Date: Mar 13, 2013
Visit Reason
This post-certification revisit was conducted to verify that deficiencies previously reported on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
The report confirms that all previously cited deficiencies identified by their regulation numbers (483.20(d), 483.20(k)(1), 483.25(i), 483.25(l), and 483.60(c)) were corrected as of the revisit date.
Deficiencies (4)
Deficiency related to regulation 483.20(d), 483.20(k)(1)
Deficiency related to regulation 483.25(i)
Deficiency related to regulation 483.25(l)
Deficiency related to regulation 483.60(c)
Report Facts
Deficiencies corrected: 4
Inspection Report
Re-Inspection
Census: 50
Deficiencies: 5
Date: Feb 11, 2013
Visit Reason
The inspection was a Health Resurvey conducted to assess compliance with previously identified deficiencies and regulatory requirements.
Findings
The facility failed to develop comprehensive care plans addressing nutritional risks, maintain acceptable nutritional status for a resident with significant weight loss, ensure drug regimens were free from unnecessary drugs, and properly monitor and document PRN medication administration and effectiveness. The pharmacist also failed to identify irregularities and notify appropriate staff regarding medication regimen issues.
Deficiencies (5)
Failed to develop a comprehensive care plan addressing nutritional risks for 1 of 21 residents.
Failed to maintain acceptable nutritional status and notify consultant of continued weight loss for 1 of 3 residents reviewed for nutrition.
Failed to ensure drug regimen was free from unnecessary drugs by not identifying and implementing non-pharmacological sleep interventions prior to hypnotic use and failing to follow up on hypnotic effectiveness.
Failed to monitor and document effectiveness of PRN medications including Ambien, Xanax, Oxycodone, and Phenergan, and failed to document reasons for administration.
Pharmacist failed to identify irregularities regarding PRN medication follow-up and failed to notify physician and director of nursing of irregularities.
Report Facts
Facility census: 50
Residents sampled for care plan: 21
Residents reviewed for nutrition: 3
Residents sampled for unnecessary drug review: 10
Weights of resident #67: 197.8
Weights of resident #67: 191
Weights of resident #67: 186
Weights of resident #67: 180
Weights of resident #67: 177
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative nursing staff C | Administrative Nursing Staff | Interviewed regarding care plan development, nutritional assessments, and medication administration documentation |
| Administrative nursing staff K | Administrative Nursing Staff | Reported developing resident #67's care plan but did not include nutrition |
| Consultant J | Consultant | Reported completing nutritional assessments and confirmed facility needed to notify consultant of weight loss |
| Consultant staff E | Consultant Pharmacist | Reported not reviewing all PRN medication follow-up and not including PRN follow-up in medication regimen review |
| Licensed nurse B | Licensed Nurse | Reported on PRN medication administration and documentation practices |
| Licensed nurse I | Licensed Nurse | Reported on PRN medication documentation practices |
| Direct care staff A | Direct Care Staff | Reported on PRN medication administration and follow-up procedures |
| Administrative nurse C | Administrative Nurse | Reported on PRN medication administration, documentation, and nurse inservice |
Inspection Report
Plan of Correction
Deficiencies: 5
Date: N087012 POC 9IU911
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited in a prior survey (Deficiency Report 2567).
Findings
The Plan of Correction outlines the facility's intended corrective actions to address issues related to quality assurance, nutritional risk, medication administration, and consultant pharmacist reviews to achieve substantial compliance by specified dates in early 2013.
Deficiencies (5)
Quality Assurance efforts to maintain substantial compliance with participation requirements.
Care plans for residents at nutritional risk and/or with weight loss need review and updating.
Residents identified at nutritional risk require dietician consultation upon admission and during stay.
Medication regimen for certain residents to be reviewed by physician; education on PRN medication administration provided to nursing staff.
Consultant pharmacist to review Medication Administration Records for irregularities and ensure adequate monitoring.
Report Facts
Complete Date: Mar 1, 2013
Complete Date: Jan 20, 2013
Complete Date: Mar 13, 2013
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Frank Dungan | Administrator | Submitted the Plan of Correction |
Inspection Report
Plan of Correction
Deficiencies: 4
Date: N087012 POC TFNY11
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified in a prior complaint investigation survey (ML Goddard complaint 04222016).
Complaint Details
This Plan of Correction is in response to deficiencies cited during the ML Goddard complaint investigation dated 04/22/2016.
Findings
The facility outlines corrective actions to address deficiencies related to involuntary discharge documentation, catheter care procedures, and oxygen equipment care, aiming to achieve substantial compliance by specified dates in April and May 2016.
Deficiencies (4)
Failure to ensure documentation by physician of rationale for involuntary discharges prior to serving discharge notice.
Failure to provide written notice to resident and family in event of involuntary discharge.
Inadequate catheter care/handling procedures by nursing staff.
Inadequate oxygen equipment care and usage procedures.
Report Facts
Complete Date: Apr 29, 2016
Complete Date: Apr 26, 2016
Complete Date: May 4, 2016
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Frank Dungan | Administrator | Submitted the Plan of Correction |
Inspection Report
Plan of Correction
Deficiencies: 7
Date: N087012 POC WXCP11
Visit Reason
This document is a Plan of Correction submitted by the facility to address deficiencies cited in a prior inspection report.
Findings
The Plan of Correction outlines specific corrective actions for multiple deficiencies related to resident care plans, fall interventions, medication administration, and facility maintenance, with timelines for achieving substantial compliance.
Deficiencies (7)
Deficiency related to care plans for residents at risk of constipation and/or with constipation.
Deficiency related to care plans reflecting fall interventions for residents at risk and/or with history of falls.
Deficiency related to monitoring and intervention for residents with constipation.
Deficiency related to staff education and communication of fall interventions.
Deficiency related to administration and monitoring of PRN medications.
Deficiency related to documentation of medication administration times on Medication Administration Record.
Deficiency related to installation and maintenance of a permanent exhaust fan in the beauty shop.
Report Facts
Residents discharged: 1
Residents at risk: 15
Audit duration: 2
Completion dates: Jun 16, 2014
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N087012 1B0N11
Visit Reason
This document is a Plan of Correction related to a facility inspection event identified by State ID N087012 and ASPEN Event ID 1B0N11.
Findings
No specific deficiencies or findings are detailed in this document; it appears to be a placeholder or status page for the Plan of Correction with no records found.
Inspection Report
Plan of Correction
Deficiencies: 6
Date: N087012 POC 4YEQ11
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a prior survey.
Findings
The facility identified multiple deficiencies including environmental maintenance issues, chemical and equipment storage, medication administration errors, insulin storage, wound care procedures, and dietary management. Corrective actions and staff education were implemented with timelines for substantial compliance.
Deficiencies (6)
Cove bases, floor tiles, and door frames in residents' rooms were deficient and required cleaning, repair, or replacement; wallpaper in the dining area needed repair.
Improper chemical storage, equipment storage, and door alarm procedures.
Medication administration record review revealed medications not administered to Resident #75; staff educated on medication administration and reordering.
Medications checked for expiration; staff educated on proper insulin storage and discard procedures.
Wound care procedures for Resident #39; staff educated on clean dressing change procedures.
Dietary manager enrolled in dietary classes with expected certification by December 2015.
Report Facts
Deficiency completion dates: Oct 15, 2015
Deficiency completion dates: Oct 22, 2015
Deficiency completion dates: Oct 2, 2015
Deficiency completion dates: Dec 24, 2015
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