Inspection Reports for
Ml-Op Goddard, LLC

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.

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.

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.

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.

This Plan of Correction is linked to a complaint investigation at Medicalodges Goddard dated 06/29/2018.

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.

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.

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.

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.

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.

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.

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.

The deficiency cited on 11/6/17 was corrected effective 11/7/17 as noted in the plan of correction.

All deficiencies have been corrected and no new noncompliance was found as of the date of the Plan of Correction.

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.

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.

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.

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.

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.

This Plan of Correction addresses deficiencies identified during a complaint investigation related to notification failures and clinical monitoring.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

This Plan of Correction is in response to a complaint investigation identified as ML Goddard complaint dated 05/19/2016.

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.

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.

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.

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.

Complaint investigation #93102 focused on issues including involuntary discharge procedures, catheter care, and oxygen therapy management.

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.

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.

The report documents that all previously cited deficiencies were corrected as of the revisit date, with corrections completed for multiple regulatory items.

The report confirms that previously identified deficiencies, specifically related to regulation 28-39-158(a), were corrected as of the revisit date.

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.

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.

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.

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.

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.

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.

This Plan of Correction addresses deficiencies identified in a complaint investigation survey.

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.

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.

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.

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.

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.

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.

The report confirms that all previously cited deficiencies identified by their regulation numbers have been corrected as of the revisit date.

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.

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.

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.

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.

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.

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.

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.

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.

This Plan of Correction is in response to deficiencies cited during the ML Goddard complaint investigation dated 04/22/2016.

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.

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.

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.