Inspection Reports for
Ml-Op Goddard, LLC
501 EASY STREET, GODDARD, KS, 67052-9235
Back to Facility ProfileDeficiencies (last 7 years)
Deficiencies (over 7 years)
22 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
267% worse than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
32
24
16
8
0
Occupancy
Latest occupancy rate
25% occupied
Based on a October 2019 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Annual Inspection
Census: 15
Deficiencies: 9
Date: Oct 15, 2019
Visit Reason
Licensure resurvey of a residential healthcare facility to assess compliance with health care services, medication administration, resident safety, emergency preparedness, and facility maintenance.
Findings
The facility failed to ensure licensed nurse oversight of health care services and medication plans, proper documentation of incidents, secure storage of chemicals, proper labeling of over-the-counter medications, safeguarding of resident records, and adequate emergency preparedness including evacuation drills and quarterly plan reviews.
Deficiencies (9)
KAR 26-41-204 (a) The administrator failed to ensure a licensed nurse provided or coordinated necessary health care services for 6 of 7 residents regarding pressure ulcer care, ADL assistance, assistive devices, falls, and behavioral management.
KAR 26-41-204 (d) The administrator failed to ensure each resident's negotiated service agreement contained the name of the licensed nurse responsible for implementation and supervision of the health care service plan for 7 of 7 residents.
KAR 26-41-205 (d) (4) The administrator failed to ensure a licensed nurse oriented and instructed 3 certified medication aides in blood sugar testing and insulin pen use, and failed to document competency.
KAR 26-41-205 (g) (3) The administrator failed to ensure licensed nurse or pharmacist labeled over-the-counter medications with the resident's full name for 10 residents.
KAR 26-41-105 (c) The administrator failed to safeguard resident records against unauthorized use by leaving all 15 residents' paper charts and confidential information in an open, accessible nursing station.
KAR 26-41-105 (f) (11) The administrator failed to document all incidents, symptoms, and indications of illness or injury including date, time, action taken, and results for 2 of 3 sampled residents regarding pressure ulcer and hospital return.
KAR 26-41-104 (a) The administrator failed to conduct an annual emergency evacuation drill with the least amount of staff on duty to ensure sufficient staff to assist residents requiring help to a secure location.
KAR 26-41-104 (d) (3) The operator failed to conduct quarterly reviews of the facility's emergency management plan with staff and residents since the last survey in 2017.
KAR 28-39-254 (a) The administrator failed to ensure staff secured all chemicals to maintain safety of cognitively impaired residents, personnel, and the public; unlocked cabinets contained multiple hazardous chemicals.
Report Facts
Residents with cognitive impairment: 7
Residents in facility: 15
Staff in emergency drill: 2
Residents in emergency drill: 14
Inspection Report
Plan of Correction
Deficiencies: 6
Date: Jun 13, 2019
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a prior inspection.
Findings
The plan addresses multiple deficiencies including resident rights to receive unopened mail, comprehensive assessments after significant change, care plan timing and revision, quality of care related to edema management, accident hazards related to chemical storage, and use of assistive devices during meals.
Deficiencies (6)
F576 Resident Right to Receive Unopened Mail Violation. Education was provided to staff regarding residents' rights to receive mail unopened and maintain privacy.
F637 Comprehensive Assessment After Significant Change Violation. Resident #31's assessment was updated to reflect significant change upon hospice admission, with education provided on timely completion of assessments.
F657 Care Plan Timing and Revision Violation. Resident #22's care plan was updated for appropriate use of T.E.D. hose, with education on timely implementation of physician orders and care plan updates.
F684 Quality of Care. Resident #22's care plan was reviewed and updated for edema care, with staff education and monitoring to ensure compliance with care plans.
F689 Free of Accident Hazards/Supervision/Devices Violation. Bleach Sani-Cloth wipes were removed from an accessible location and staff educated on chemical storage safety.
F810 Assistive Devices - Eating Equipment/Utensils. Resident #41 was ensured to have assistive devices offered during meals, with staff education and daily monitoring.
Inspection Report
Complaint Investigation
Census: 47
Deficiencies: 6
Date: May 30, 2019
Visit Reason
The inspection was conducted as a Health Resurvey and Complaint Investigation involving multiple complaint case numbers.
Complaint Details
The inspection included complaint investigations identified by case numbers KS00141157, KS00141158, KS00139467, KS00140851, and KS00140622.
Findings
The facility was found deficient in multiple areas including failure to ensure resident mail privacy, failure to complete significant change assessments, inadequate care plan interventions for edema and T.E.D. hose use, failure to ensure resident wore T.E.D. hose as ordered, failure to secure hazardous chemicals, and failure to provide weighted silverware to a resident as per care plan.
Deficiencies (6)
§483.10(g)(9) The facility failed to ensure resident #37 received his/her mail unopened, violating resident privacy rights.
§483.20(b)(2)(ii) The facility failed to complete a significant change minimum data set assessment for resident #31 upon admission to hospice.
§483.21(b)(2)(i)-(iii) The facility failed to place interventions on resident #22's care plan for edema and required T.E.D. hose use.
§483.25 Quality of care The facility failed to ensure resident #22 wore T.E.D. hose according to physician orders.
§483.25(d)(1)(2) The facility failed to lock up bleach Sani-Cloth wipes, allowing 9 cognitively impaired residents access to hazardous chemicals.
§483.60(g) The facility failed to ensure resident #41 received weighted silverware per his/her preference and care plan during meal times.
Report Facts
Facility census: 47
Number of cognitively impaired residents with access to hazardous chemicals: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Administrative Office Staff | Named in mail privacy deficiency for opening resident #37's mail. |
| Administrative Licensed Nurse C | Licensed Nurse | Interviewed regarding expectation of significant change MDS assessments. |
| Administrative Licensed Nurse D | Administrative Nurse | Interviewed regarding expectations for MDS assessments, care plans, T.E.D. hose use, and hazardous chemical storage. |
| Licensed Nurse E | Licensed Nurse | Interviewed regarding resident #22's T.E.D. hose use and staff notification. |
| Direct Care Staff F | Direct Care Staff | Interviewed about therapy communication regarding weighted silverware. |
| Dietary Aide G | Dietary Aide | Interviewed about awareness of resident #41's weighted silverware needs. |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Nov 27, 2018
Visit Reason
An offsite revisit survey was conducted to verify correction of 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.
Inspection Report
Plan of Correction
Deficiencies: 9
Date: Sep 26, 2018
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified during an annual survey inspection, including incidents of resident-to-resident altercation, falls with injury, and other care concerns.
Findings
The facility reported multiple incidents including resident-to-resident altercation and falls with injury. Corrective actions include staff education, care plan updates, monitoring of risk events, and audits to ensure compliance with federal and state regulations.
Deficiencies (9)
F609-E Resident #40 and #100 resident-to-resident altercation occurred on 9/6/18 and was reported during the annual survey. Resident #4 and #41 had falls with injury reported during the survey period. Mandatory staff in-service on abuse, neglect, and exploitation was scheduled.
F610-E Resident #40 and #100 incident was re-investigated and confirmed as resident-to-resident altercation. Falls of residents #4, #41, and bruise of resident #44 were reviewed and interventions implemented to prevent further incidents.
F641-D Resident #40 and #24 MDS assessments were modified. All resident MDS will be reviewed and education provided to ensure accurate coding.
F657-D Care plans for residents #24, #40, #41, and #4 were updated to reflect interventions to prevent further falls. Staff education on care plan updates was scheduled.
F661-D Resident #45 was discharged. Education on discharge summary completion was provided to the IDT team. Monitoring of discharge documentation was implemented.
F689-E Care plans for residents #4, #40, #41, and #44 were reviewed for appropriate fall and injury interventions. Staff education on fall prevention and injury interventions was conducted.
F756-D Licensed nurses received education on medication refusal, parameters, and physician notification. Monitoring of nursing notes and physician notifications was established.
F812-F Kitchen and food preparation areas were cleaned and repaired. Dietary staff received education on food storage and cleaning techniques. A weekly audit system was implemented.
F880-F Laundry table was repaired. Laundry and nursing staff received in-service training on infection control practices. Weekly audits and root cause analysis were established.
Report Facts
Date of resident altercation: Sep 6, 2018
Date of resident falls: Apr 20, 2018
Date of resident falls: Sep 13, 2018
Date of bruise report: Sep 4, 2018
Discharge date: Jun 20, 2018
Plan of correction completion date: Oct 19, 2018
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jean Altenor | Administrator | Administrator submitting the Plan of Correction |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Sep 26, 2018
Visit Reason
The visit was conducted to determine if the facility was 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 based on credible allegation of compliance and evidence of correction.
Deficiencies (1)
The facility had a 'F' level deficiency that was widespread and constituted no actual harm but had potential for more than minimal harm without 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
Complaint Investigation
Census: 43
Deficiencies: 9
Date: Sep 26, 2018
Visit Reason
The inspection was conducted as a Health Resurvey and Complaint Investigation related to allegations of abuse, neglect, and failure to provide planned services to prevent falls.
Complaint Details
The complaint investigation was substantiated with findings of failure to report and investigate abuse/neglect incidents, failure to prevent accidents, and other regulatory deficiencies as detailed in the findings.
Findings
The facility failed to report incidents of alleged abuse/neglect involving multiple residents, failed to thoroughly investigate these incidents, and failed to complete accurate assessments and timely revise care plans. Additional findings included failure to complete medication reconciliation upon discharge, failure to prevent accidents due to inadequate supervision and assistive devices, failure to identify and report medication irregularities, failure to maintain sanitary food preparation and storage conditions, and failure to maintain an effective infection prevention and control program.
Deficiencies (9)
F 609: The facility failed to report 3 incidents of alleged abuse/neglect involving 4 residents to the state agency, including a resident to resident altercation and neglect related to fall prevention.
F 610: The facility failed to thoroughly investigate 3 incidents of alleged abuse/neglect involving 4 residents, including lack of notarized witness statements and root cause analysis.
F 641: The facility failed to complete accurate minimum data sets for 2 residents related to functional limitation of range of motion.
F 657: The facility failed to timely revise care plans for 4 residents following falls, lacking updated interventions and assessments.
F 661: The facility failed to complete medication reconciliation for a resident discharged against medical advice.
F 689: The facility failed to prevent accidents for 4 residents by not ensuring adequate supervision and assistive devices, and failed to conduct thorough root cause analysis.
F 756: The facility consultant pharmacist failed to identify and report medication irregularities for 3 residents, including multiple medication refusals and blood pressure readings out of parameters.
F 812: The facility failed to store and prepare food under sanitary conditions, including dusty ceiling fans, dirty ventilation units, damaged cutting boards and spatulas, dirty cabinet doors, faulty refrigerator door seals, and grime buildup.
F 880: The facility failed to maintain an infection prevention and control program by not tracking and trending infections and failing to maintain sanitary laundry facilities.
Report Facts
Resident census: 43
Number of residents sampled: 18
Number of abuse/neglect incidents not reported: 3
Number of infections in July 2018: 6
Number of infections in August 2018: 8
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Sep 18, 2018
Visit Reason
A revisit survey was conducted to verify correction of all previous deficiencies cited on 2018-06-29.
Findings
All deficiencies cited in the previous inspection have been corrected as of the compliance date 2018-07-10. No new noncompliance was found and the facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 0
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Sep 18, 2018
Visit Reason
A revisit survey was conducted to verify correction of all previous deficiencies cited on 2018-06-29.
Findings
All deficiencies cited in the prior inspection have been corrected as of the compliance date 2018-07-10, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
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.
Findings
The facility submitted a written plan addressing wound monitoring and treatment to prevent pressure ulcers, including staff education, order audits, and ongoing monitoring until compliance is achieved.
Deficiencies (2)
F658 Services Provided Meet Professional Standard. Staff education was provided regarding wound monitoring from identification until healed, including weekly skin assessments and physician notification. The Director of Nursing or designee will audit new orders and monitor compliance until substantial compliance is attained.
F686 Treatment/Services to Prevent Heal Pressure Ulcers. Staff education was provided on wound monitoring and weekly skin assessments. The Director of Nursing or designee will monitor wound logs and care plan compliance with ongoing audits until substantial compliance is attained.
Inspection Report
Complaint Investigation
Census: 50
Deficiencies: 2
Date: Jun 29, 2018
Visit Reason
The inspection was conducted as a complaint investigation related to allegations concerning the care of Resident #1, specifically regarding failure to follow physician orders for wound care and arterial Doppler studies.
Complaint Details
The complaint investigations #KS 00130650 and KS 00130687 were related to failure to follow physician orders for wound care and arterial Doppler studies for Resident #1, resulting in worsening pressure ulcer and eventual death due to infection.
Findings
The facility failed to meet professional standards of care by not following physician orders for arterial Doppler studies and wound care for Resident #1's unstageable left foot ulcer. The resident developed an unstageable pressure ulcer during the stay, and the facility failed to notify the physician of worsening wound conditions and failed to send the resident to the wound care center as ordered. Resident #1 was transferred to the hospital late and subsequently died due to infection complications.
Deficiencies (2)
F 658: The facility failed to follow physician's orders for arterial Doppler studies and timely wound care for Resident #1's unstageable left foot ulcer.
F 686: The facility failed to provide care consistent with professional standards to prevent and treat an unstageable pressure ulcer on Resident #1's left foot, including failure to notify the physician of worsening condition and failure to send the resident to wound care as ordered.
Report Facts
Facility census: 50
Pressure ulcer measurements: 1.8
Pressure ulcer measurements: 2.1
Antibiotic treatment duration: 8
Antibiotic treatment duration: 2
BIMS score: 10
Intravenous antibiotic treatment duration: 4
Intravenous antibiotic treatment duration: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed nurse C | Observed wound worsening and notified APRN on 6/14/2018; involved in transfer order | |
| Licensed nurse B | Called VA for update on Resident #1; involved in transfer order and wound care communication | |
| Licensed nurse D | Received orders from APRN on 6/14/2018; failed to complete Doppler and wound care orders; no longer employed |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jan 9, 2018
Visit Reason
This document is a Plan of Correction related to a prior inspection event identified as G03B12 for the facility with State ID N087012.
Findings
No deficiency records or findings are included in this Plan of Correction document.
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 confirm the date such corrective actions were accomplished.
Findings
The report shows that all previously cited deficiencies identified by regulation numbers 26-41-101 (f)(3), 26-41-104 (d), and 26-41-206 (d) were corrected as of the revisit date.
Deficiencies (3)
Regulation 26-41-101 (f)(3): Previously cited deficiency corrected as of 12/27/2017.
Regulation 26-41-104 (d): Previously cited deficiency corrected as of 12/27/2017.
Regulation 26-41-206 (d): Previously cited deficiency corrected as of 12/27/2017.
Inspection Report
Follow-Up
Deficiencies: 3
Date: Dec 27, 2017
Visit Reason
This revisit inspection was conducted to verify that previously cited deficiencies have been corrected by the facility.
Findings
All previously reported deficiencies identified by regulation or Life Safety Code provisions were corrected as of the revisit date.
Deficiencies (3)
Regulation 26-41-101 (f) (3) deficiency was corrected by 12/27/2017.
Regulation 26-41-104 (d) deficiency was corrected by 12/27/2017.
Regulation 26-41-206 (d) deficiency was corrected by 12/27/2017.
Inspection Report
Re-Inspection
Census: 18
Deficiencies: 3
Date: Dec 6, 2017
Visit Reason
This was a resurvey of the residential health care facility conducted on 12/4/17, 12/5/17, and 12/6/17 to verify correction of previous deficiencies.
Findings
The administrator failed to report and investigate an allegation of potential abuse within 24 hours. The facility did not conduct quarterly reviews of the emergency management plan with residents and employees. Food was not served at the proper temperature, and food temperature monitoring was inadequate.
Deficiencies (3)
KAR 26-41-101(f)(3)(A) 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 or neglect.
KAR 26-41-104(d) The administrator failed to ensure quarterly review of the facility's emergency management plan with residents and employees.
KAR 26-41-206(d) The administrator failed to ensure food was served to residents at the proper temperature and food temperatures were not measured or recorded prior to serving.
Report Facts
Census: 18
Sample size: 3
Food temperatures: 141.1
Food temperatures: 149
Food temperatures: 175.6
Food temperatures: 174.3
Last recorded food temperature date: May 26, 2014
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 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: 0
Date: Dec 5, 2017
Visit Reason
This document is a plan of correction submitted in response to a previously cited deficiency (F280, 'D' level) from an off-site survey conducted on 2017-11-06.
Findings
The deficiency cited on 2017-11-06 was corrected effective 2017-11-07. No additional deficiencies or findings are detailed in this document.
Report Facts
Deficiency cited: 1
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Dec 5, 2017
Visit Reason
A revisit survey was conducted to verify correction of all previous deficiencies cited on 2017-10-18.
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
Plan of Correction
Deficiencies: 1
Date: Dec 5, 2017
Visit Reason
This document is a Plan of Correction submitted by the facility to address deficiencies identified in a prior inspection.
Findings
All deficiencies have been corrected and no new noncompliance was found as of the date of this Plan of Correction.
Deficiencies (1)
All deficiencies have been corrected and no new noncompliance was found.
Inspection Report
Plan of Correction
Deficiencies: 3
Date: Nov 7, 2017
Visit Reason
The document is a Plan of Correction submitted in response to deficiencies identified in a prior complaint investigation.
Findings
The facility identified issues related to resident care plans, specifically regarding elopement risk assessment and care plan updates. The plan outlines corrective actions including care plan revisions, staff in-service training, and ongoing monitoring by the Quality Assurance committee.
Deficiencies (3)
F0000: The facility will adjust Quality Assurance efforts to maintain substantial compliance with participation requirements. A copy of this plan will be provided to the QA committee at their next scheduled meeting.
F280-D: Resident #1's care plan was reviewed and updated based on assessment findings and event investigation to prevent re-occurrence. All residents were checked for elopement risk and care plans were updated accordingly with mandatory staff in-service planned.
F323-J: Past noncompliance noted with no Plan of Correction required.
Inspection Report
Complaint Investigation
Census: 42
Deficiencies: 2
Date: Nov 6, 2017
Visit Reason
The inspection was a partial extended survey and complaint investigation triggered by a complaint regarding elopement and care plan revision.
Complaint Details
Complaint investigation #KS00122629 involved a resident who eloped from the facility on 10/20/17, was found injured near a busy highway, and had missing corrective lenses. The facility failed to implement an elopement care plan after assessing the resident as high risk on 10/15/17. The resident eloped again on 10/21/17. The facility's door alarms did not sound during the elopements, and staff failed to provide adequate supervision.
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 and implement appropriate care plan interventions prior to the elopement.
Deficiencies (2)
F280: The facility failed to implement interventions to reduce elopement risk for a cognitively impaired resident assessed as high risk, resulting in an elopement incident.
F323: The facility failed to identify a resident as an elopement risk and implement adequate supervision and interventions, placing the resident in immediate jeopardy when he/she eloped, sustained injuries, and lost corrective lenses.
Report Facts
Facility census: 42
Distance eloped: 862
BIMS score: 10
BIMS score: 14
Elopement risk score: 3
Elopement risk score: 14
Elopement risk score: 29
Temperature: 72
Speed limit: 50
Speed limit: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative nurse B | Administrative Nurse | Confirmed resident was identified as elopement risk prior to elopement and failure to implement care plan interventions |
| Licensed nurse C | Licensed Nurse | Identified resident missing during elopement and involved in elopement incident response |
| Direct care staff D | Direct Care Staff | Located resident after elopement and returned resident to facility |
| Direct care staff G | Direct Care Staff | Reported resident was not identified on care plan as elopement risk before 10/20/17 |
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 Immediate Jeopardy and Past Non-compliance related to resident health or safety for F323, and a deficiency at F280 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)
F323 was cited for Immediate Jeopardy and Past Non-compliance related to resident health or safety under 42 CFR 483.25(d)(1)(2)(n)(1)-(3).
F280 was cited at a 'D' level deficiency.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Caryl Gill | Complaint Coordinator | Named as contact and signatory related to survey findings and plan of correction. |
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 the facility was not in substantial compliance and constituted Immediate Jeopardy, 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)
The facility was found not in substantial compliance with Federal participation requirements, constituting Immediate Jeopardy and Past Non-compliance related to 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 | Signed the report |
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 the facility was not in substantial compliance and constituted Immediate Jeopardy, Past Non-compliance to resident health or safety for F323, "J" CFR 483.25(d)(1)(2)(n)(1)-(3). Enforcement remedies will be recommended without opportunity for correction.
Deficiencies (1)
The facility was found not in substantial compliance with Federal participation requirements, constituting Immediate Jeopardy and Past Non-compliance related to 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 in the letter |
Inspection Report
Plan of Correction
Deficiencies: 2
Date: Oct 19, 2017
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited in a complaint investigation survey (Medicalodges Goddard Complaint 101817).
Findings
The facility identified issues related to timely physician notification of changes in resident conditions and critical lab values. The Plan of Correction outlines staff training, monitoring, and quality assurance measures to ensure compliance and appropriate follow-up.
Deficiencies (2)
F157-D: Resident #1 physician notified of change of condition and critical lab value on 8/29/17; family notification delayed until next day. Resident #2 labs reviewed to ensure appropriate notifications and follow-up completed.
F309-G: Resident #1 physician notified of change of condition and critical lab value on 8/29/17; family notification delayed until next day. Resident #2 orders reviewed and updated for monitoring and physician notification parameters.
Report Facts
Date of Plan of Correction completion: Oct 18, 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 compliance with Federal participation requirements for nursing homes in the Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies at F309, rated 'G', indicating actual harm that is not immediate jeopardy. Due to these deficiencies, the facility will not be given an opportunity to correct before enforcement remedies are imposed.
Deficiencies (1)
Deficiency F309 was cited at a severity level 'G', indicating actual harm that is not immediate jeopardy. Corrections are required as evidenced by the CMS-2567L.
Report Facts
Denial of payment effective date: Nov 7, 2017
Termination recommendation date: Apr 18, 2018
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Frank Dungan | Administrator | Named as facility administrator in the report. |
| Caryl Gill | Enforcement Coordinator | Named as enforcement coordinator issuing the letter. |
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 sampled residents.
Complaint Details
Complaint investigation #121644 focused on failure to notify physician and resident representatives of changes in condition and critical lab values for 2 residents. The investigation found substantiated failures in notification and assessment.
Findings
The facility failed to notify the physician and resident representative of changes in condition and critical lab values for 2 sampled residents. Resident #1 experienced a decline in condition with critical lab values not promptly communicated, resulting in delayed hospital transfer. Resident #2 had critical lab values that were not reported to the physician. The facility also failed to provide timely nurse assessments, monitor vital signs, and manage fluid restrictions and dialysis care as ordered.
Deficiencies (2)
483.10(g)(14) Notification of Changes. The facility failed to ensure staff notified the physician, resident, and/or resident representative for 2 sampled residents with changes in condition and critical lab values.
483.24, 483.25(k)(l) Provide care/services for highest well being. The facility failed to ensure 2 sampled residents received nurse assessments following changes in condition, monitoring of health conditions, and timely response to critical lab results.
Report Facts
Facility census: 44
Critical Troponin level: 15.47
White blood cell count: 15.5
BNP level: 2510
Critical creatinine level: 7.11
Critical creatinine level: 9.84
BIMS score: 3
BIMS score: 15
Resident weight: 225.6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse H | Licensed Nurse | Received critical lab results for Resident #1 on 8/29/17 and contacted on-call physician extender. |
| Physician Extender J | Physician Extender | Provided orders to Nurse H on 8/29/17 and did not recall receiving critical lab call. |
| Licensed Nurse D | Licensed Nurse | Responsible for Resident #2 care and notified of critical labs but failed to notify physician. |
| Licensed Nurse K | Licensed Nurse | Reported resident condition changes and family concerns but did not perform assessments. |
| Direct Care Staff E | Reported changes in Resident #1 condition to nursing staff. | |
| Direct Care Staff M | Reported decline in Resident #1 condition to nursing staff. | |
| Direct Care Staff N | Observed changes in Resident #1 condition and reported to nursing staff. | |
| Administrative Nurse B | Administrative Nurse | Provided expectations for nurse notification and assessments. |
| Licensed Nurse C | Licensed Nurse | Monitored Resident #1 condition and placed resident on doctor's list. |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Apr 30, 2017
Visit Reason
This visit was conducted as a post-certification revisit to verify that previously cited deficiencies have been corrected.
Findings
The report confirms that all previously reported deficiencies identified by regulation numbers 483.25(d)(1)(2)(n)(1)-(3), 483.60(i)(1)-(3), and 483.90(i)(5) have been corrected as of the revisit date.
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 to assess compliance with regulations related to resident safety and food service sanitation.
Complaint Details
The visit was triggered by complaints regarding resident falls and food safety concerns. The complaint investigation found substantiated issues with fall prevention and food sanitation.
Findings
The facility failed to identify causal factors and plan appropriate interventions to prevent further falls for two residents, and failed to maintain sanitary food storage practices by not marking and dating food items and discarding expired food. Additionally, the kitchen floor was found to be damaged and not cleanable, posing a sanitary risk.
Deficiencies (3)
F323: The facility failed to identify causal factors and plan appropriate interventions to prevent further falls for residents #53 and #31, despite multiple falls and documented risks.
F371: The facility failed to maintain, store, and serve food under sanitary conditions by failing to mark and date food items and discarding expired food, potentially affecting all 50 residents.
F465: The facility failed to ensure the kitchen floor remained intact, clean, and with a cleanable surface, with broken flooring around drains and stained areas, posing a sanitary risk to all residents.
Report Facts
Facility census: 50
Fall risk score: 15
Fall risk score: 16
Fall risk score: 21
Expired food date: 2017
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative nurse I | Administrative Nurse | Reported nurses were responsible for updating care plans after falls |
| Licensed nurse H | Licensed Nurse | Reported resident's decline and fall incidents |
| Direct care staff D | Reported resident's transfer attempts and fall circumstances | |
| Direct care staff E | Observed assisting resident with transfers and toileting | |
| Direct care staff F | Reported resident's assistance needs and fall history | |
| Direct care staff G | Reported resident's use of call light and assistance | |
| Licensed staff J | Licensed Staff | Reported resident's independence and call light use |
| Administrative nursing staff K | Administrative Nursing Staff | Reported on nutrition room access and expired food |
| Maintenance staff C | Maintenance Staff | Reported on kitchen floor condition and communication with administration |
| Administrative staff A | Administrative Staff | Reported knowledge of kitchen floor condition and communication with home office |
| Dietary staff B | Dietary Staff | Reported attempts to clean kitchen floors and acknowledged floor damage |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Apr 5, 2017
Visit Reason
The visit was conducted to determine if the facility was 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, and the facility was found to be in substantial compliance effective April 30, 2017.
Deficiencies (1)
The survey found 'F' level deficiencies that were widespread and constituted no actual harm but had potential for more than minimal harm without immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure Certification & Enforcement Manager | Signed letter accepting plan of correction and confirming substantial compliance. |
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 a prior inspection report (2567 Medicalodges Goddard 040517).
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, implementing audit systems, and repairing kitchen floor tiles.
Deficiencies (3)
F323-D Resident #31 and #53 care plans for fall interventions were reviewed and revised to reflect appropriate interventions related to falls. Staff was educated on the Fall Management Policy and ongoing audits will monitor compliance.
F371-F Staff received in-service training on proper storage and labeling of food on 4/18/17. A weekly audit system was implemented to monitor labeling and dating of food.
F465-F Floor tiles in the kitchen were assessed and determined repairable by replacing damaged and stained tiles. Monthly inspections and tile replacements will be conducted to maintain compliance.
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 complied with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies at the facility 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 to address these deficiencies.
Deficiencies (1)
The facility was cited for deficiencies at the 'F' severity level related to Life Safety Code compliance. These deficiencies posed no immediate jeopardy but had potential for more than minimal harm.
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 complied 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)
The facility was cited for deficiencies at the 'F' level under the Life Safety Code survey, indicating no harm but potential for more than minimal harm without immediate jeopardy.
Inspection Report
Plan of Correction
Deficiencies: 2
Date: May 31, 2016
Visit Reason
The document is a Plan of Correction submitted in response to deficiencies identified in a prior complaint investigation survey.
Findings
The facility plans to adjust its quality assurance efforts to maintain compliance and will conduct staff in-service training on abuse, neglect, and misappropriation of property by May 31, 2016. Training will be conducted annually and monitored by the administrator.
Deficiencies (2)
F0000: The facility will adjust quality assurance efforts to maintain substantial compliance with participation requirements. A copy of this plan will be provided to the QA committee.
F225-D: Staff will receive in-service training on abuse, neglect, and misappropriation of property by 05/31/2016. Training will include reporting requirements and be conducted annually.
Inspection Report
Follow-Up
Deficiencies: 1
Date: May 31, 2016
Visit Reason
This visit was conducted as a post-certification revisit to verify that previously identified deficiencies have been corrected.
Findings
The report confirms that the deficiencies previously cited under regulation 483.13(c)(1)(ii)-(iii), (c)(2)-(4) have been corrected as of the revisit date.
Deficiencies (1)
Regulation 483.13(c)(1)(ii)-(iii), (c)(2)-(4) deficiencies previously cited have been corrected as of 05/31/2016.
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 that constitutes no actual harm with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction and was found to be in substantial compliance based on the credible allegation of compliance and the plan.
Deficiencies (1)
The facility had a 'D' level deficiency that constitutes no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Inspection Report
Complaint Investigation
Census: 55
Deficiencies: 1
Date: May 19, 2016
Visit Reason
The inspection was conducted as a complaint investigation triggered by allegations of misappropriation/exploitation of resident property.
Complaint Details
The complaint investigation involved allegations of misappropriation/exploitation of resident #1's cell phone. The allegation was not reported to the state agency, and the facility failed to provide evidence of a complete investigation.
Findings
The facility failed to report an allegation of misappropriation/exploitation of a resident's property and did not have evidence of a thorough investigation for one sampled resident. The resident's cell phone was reportedly used by someone else without consent, but the facility did not report this to the state agency as required.
Deficiencies (1)
F225: The facility failed to report an allegation of misappropriation/exploitation of resident #1's property to the state agency and lacked evidence of a thorough investigation into the allegation.
Report Facts
Facility census: 55
Residents sampled for missing property: 3
BIMS score: 15
Phone bill amount: 100
Inspection Report
Follow-Up
Deficiencies: 0
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 had 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.
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 based on the credible allegation of compliance.
Deficiencies (1)
The facility had 'D' level deficiencies indicating no actual harm but potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Caryl Gill | Complaint Coordinator | Named as contact and signatory related to the survey findings and plan of correction. |
Inspection Report
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 but have potential for more than minimal harm without immediate jeopardy. The facility submitted a plan of correction and was found to be in substantial compliance based on the credible allegation of compliance and the plan.
Deficiencies (1)
The facility had 'D' level deficiencies indicating no actual harm but potential for more than minimal harm that is not immediate jeopardy.
Inspection Report
Plan of Correction
Deficiencies: 4
Date: Apr 22, 2016
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified during a complaint investigation related to ML Goddard complaint dated 04/22/2016.
Complaint Details
This Plan of Correction is in response to a complaint investigation identified as ML Goddard complaint dated 04/22/2016.
Findings
The facility identified issues with documentation for involuntary discharges, catheter care procedures, and oxygen equipment care. The Plan of Correction outlines staff in-service training and monitoring to ensure compliance and prevent recurrence.
Deficiencies (4)
F202-D: Facility will ensure documentation by physician of rationale for involuntary discharges is present in the clinical record prior to serving a discharge notice.
F203-D: Facility will ensure written notice is provided to the resident and family member in the event of involuntary discharge.
F315-D: Facility nursing staff was in-serviced on catheter care procedures and will monitor compliance by random checks for 2 months.
F328-D: Facility provided in-service on oxygen equipment care and will monitor compliance by random audits for 2 months.
Inspection Report
Complaint Investigation
Census: 50
Deficiencies: 5
Date: Apr 22, 2016
Visit Reason
Complaint investigation #93102 regarding the facility's failure to properly document and notify about resident discharge and concerns about catheter care and oxygen therapy.
Complaint Details
Complaint investigation #93102 focused on documentation and notification failures related to resident discharge and deficiencies in catheter and oxygen therapy care.
Findings
The facility failed to document physician rationale for involuntary discharge, provide proper discharge notice, and maintain catheter care and oxygen therapy equipment. Deficiencies included failure to keep catheter tubing off the floor, improper perineal care, failure to provide continuous oxygen at ordered flow, and failure to clean oxygen concentrator filters as scheduled.
Deficiencies (5)
483.12(a)(3) Documentation for transfer/discharge was deficient as the facility failed to have physician documentation for involuntary discharge of resident #3 prior to serving discharge notice.
483.12(a)(4)-(6) Notice requirements before transfer/discharge were not met as the facility failed to provide proper written notice including clinical reason and discharge location for resident #3.
483.25(d) The facility failed to provide appropriate catheter care for resident #2 by not keeping catheter tubing and collection bag off the floor and failing to use separate cloths for cleaning catheter during incontinent care.
483.25(k) The facility failed to ensure resident #1 received continuous oxygen at the ordered flow and failed to maintain oxygen equipment by not changing tubing weekly and not cleaning concentrator filters as planned.
483.25(k) The facility failed to maintain oxygen equipment for resident #5 by not cleaning oxygen concentrator filters weekly as planned.
Report Facts
Facility census: 50
Residents sampled: 6
Residents sampled for catheter care: 3
Oxygen tubing change frequency: 1
Oxygen flow rate: 4
Inspection Report
Follow-Up
Deficiencies: 0
Date: Oct 22, 2015
Visit Reason
This is a post-certification revisit to verify that previously cited deficiencies have been corrected as documented on the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
The revisit confirmed that all previously reported deficiencies identified by regulation or Life Safety Code provisions have been corrected as of the revisit date.
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Oct 22, 2015
Visit Reason
This is a revisit report to verify correction of previously cited deficiencies at the facility.
Findings
The report documents that previously reported deficiencies have been corrected as of the revisit date.
Deficiencies (1)
Regulation 28-39-158(a) deficiency was corrected by 10/22/2015.
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Oct 22, 2015
Visit Reason
This visit was a follow-up to verify correction of previously reported deficiencies at the facility.
Findings
The report documents that previously identified deficiencies have been corrected as of the revisit date.
Deficiencies (1)
Regulation 28-39-158(a) deficiency was corrected by the revisit date of 10/22/2015.
Inspection Report
Follow-Up
Deficiencies: 4
Date: Oct 21, 2015
Visit Reason
This visit was conducted as a follow-up to verify correction of previously reported deficiencies.
Findings
All previously reported deficiencies identified by regulation or LSC provision numbers were corrected as of the revisit date.
Deficiencies (4)
Regulation 28-39-158(a): Previously cited deficiency corrected as of 10/21/2015.
Regulation 26-41-205 (d) (1-2): Previously cited deficiency corrected as of 10/21/2015.
Regulation 26-41-205 (e) (f): Previously cited deficiency corrected as of 10/21/2015.
Regulation 26-41-205 (h): Previously cited deficiency corrected as of 10/21/2015.
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 identified several deficiencies related to dietary management, medication administration, verbal orders, and insulin storage. Corrective actions and monitoring plans were implemented to ensure compliance.
Deficiencies (4)
Dietary manager is enrolled in dietary classes and will test for CDM certification by December 2015. The administrator and human resources will monitor status.
Pulse was added to resident #3 Digoxin orders. All medication administration records were reviewed and updated as needed. Residential Care Director will perform weekly audits for 2 months.
Resident #1 and #2 verbal orders have been signed. Residential Care Coordinator reviewed all charts for unsigned orders and will monitor compliance by weekly audits.
Certified Medication Aides were in-serviced on proper insulin storage and discard instructions. Residential Care Coordinator will perform weekly audits of medication cart for 2 months.
Inspection Report
Plan of Correction
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, and the facility was found to be in substantial compliance based on the credible allegation of compliance.
Deficiencies (1)
The facility had 'E' level deficiencies indicating no actual harm but potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed the enforcement letter regarding the plan of correction. |
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 and overall facility conditions.
Findings
The facility failed to maintain a sanitary and comfortable environment, ensure resident safety by controlling hazardous chemicals and clutter, provide timely pharmaceutical services including medication administration and monitoring for expired medications, and maintain proper infection control practices during wound care.
Deficiencies (5)
F 253: The facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary and comfortable living environment, including scuffed floors, peeling wallpaper, and damaged baseboards.
F 323: The facility failed to keep hazardous chemicals out of residents' reach, monitor exit door alarms adequately, and maintain a hallway free of clutter, creating potential accident hazards.
F 425: The facility failed to provide routine medications timely for resident #75, resulting in missed doses of Plaquenil and Zoloft for several days.
F 431: The facility failed to adequately monitor medications for expiration, with an expired Humalog insulin pen found in a medication cart.
F 441: The facility failed to use proper clean technique during wound dressing changes for resident #39, including failure to change gloves after touching potentially contaminated surfaces.
Report Facts
Resident census: 54
Residents affected by housekeeping deficiency: 11
Residents cognitively impaired and independently mobile: 3
Residents reviewed for medication: 22
Residents reviewed for unnecessary medications: 5
Expired medication found: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff G | Maintenance Staff | Reported knowledge of maintenance issues and lack of preventative maintenance plan |
| Staff O | Housekeeping Staff | Reported inability to clean tile stains and proper chemical storage |
| Staff B | Administrative Nursing Staff | Reported need for locked chemical storage and proper door alarm monitoring |
| Staff P | Direct Care Staff | Instructed nurse to silence door alarm and provided care to resident #75 |
| Staff H | Licensed Nurse | Silenced door alarm without visual check |
| Staff K | Licensed Nurse | Reported medication reorder process and improper medication administration |
| Staff Q | Licensed Nurse | Reported resident #75's medication changes and behavior |
| Staff R | Direct Care Staff | Reported resident #75's emotional state |
| 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 related to dietary services, medication administration, verbal orders, and medication storage.
Findings
The facility failed to assign a licensed dietitian or certified dietary manager as overall supervisory responsibility for dietetic services. The facility did not assess resident #3's pulse rate daily prior to Digoxin administration. Verbal medication orders for residents #1 and #2 were not signed by the medical provider within seven working days. The facility failed to label and store an insulin pen for resident #1 according to policy.
Deficiencies (4)
28-39-158(a) Dietary services. The facility failed to assign overall supervisory responsibility for dietetic services to a full-time licensed dietitian or certified dietary manager.
26-41-205 (d) (1-2) Facility administration of medications. The facility failed to assess resident #3's pulse rate daily prior to administration of Digoxin as directed.
26-41-205 (e) (f) Medication verbal orders and standing orders. The facility failed to ensure medical care provider signed all verbal orders within seven working days for residents #1 and #2.
26-41-205 (h) Medication storage. The facility failed to label and store an insulin pen for resident #1 to ensure administration within the recommended expiration date.
Report Facts
Census: 19
Sampled residents: 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
Working days late for verbal order signatures: 30
Working days late for verbal order signatures: 24
Working days late for verbal order signatures: 18
Working days late for verbal order signatures: 10
Working days late for verbal order signatures: 13
Inspection Report
Follow-Up
Deficiencies: 1
Date: Apr 24, 2015
Visit Reason
This post-certification revisit was conducted to verify that previously identified deficiencies from the CMS-2567 Statement of Deficiencies and Plan of Correction were corrected.
Findings
The revisit confirmed that the previously cited deficiency under regulation 483.25(h) was corrected as of the revisit date.
Deficiencies (1)
Regulation 483.25(h) deficiency was corrected as of 04/24/2015.
Inspection Report
Follow-Up
Deficiencies: 1
Date: Apr 24, 2015
Visit Reason
This post-certification revisit was conducted to verify that previously identified deficiencies reported on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
The report confirms that the deficiency identified under regulation 483.25(h) was corrected as of the revisit date.
Deficiencies (1)
Regulation 483.25(h): The previously cited deficiency was corrected by the revisit date of 04/24/2015.
Inspection Report
Plan of Correction
Deficiencies: 3
Date: Apr 15, 2015
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified in a complaint investigation survey.
Findings
The facility identified issues related to medication storage and fall investigations. Corrective actions include staff education, monitoring medication storage, and reviewing fall investigations with root cause analysis to ensure compliance.
Deficiencies (3)
F0000: The facility will adjust Quality Assurance efforts to maintain substantial compliance with participation requirements. A copy of this plan will be provided to the QA committee.
F323-E: Certified Medication Aides and Licensed Nurses reviewed and signed the Medication Storage Policy. The facility will monitor medication storage by random spot checks three times weekly for two months.
F323-E: Fall investigations and care plans were reviewed. Licensed nursing staff received education on fall policy and investigation procedures. Fall investigations will be reviewed monthly for compliance.
Report Facts
Residents potentially affected: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Frank Dungan | Administrator | Submitted the Plan of Correction |
Inspection Report
Complaint Investigation
Census: 56
Deficiencies: 1
Date: Apr 14, 2015
Visit Reason
The inspection was conducted as a complaint investigation based on complaint surveys #82897, #84698, and #77494.
Complaint Details
The complaint surveys #82897, #84698, and #77494 triggered this 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 implement new care plan interventions for residents #2 and #5. The facility also failed to safely store medications to prevent accidents for 12 cognitively impaired and independently mobile residents.
Deficiencies (1)
483.25(h) The facility failed to thoroughly investigate falls to determine root causes and revise care plans for 2 of 3 residents reviewed, and failed to safely store medications unattended for 12 cognitively impaired residents.
Report Facts
Facility census: 56
Residents in sample: 6
Residents cognitively impaired and independently mobile: 12
Fall risk scores: 24
Blood pressure: 220
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 Medicare and/or Medicaid programs.
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 based on the credible allegation of compliance.
Deficiencies (1)
The facility had an 'E' level deficiency indicating no actual harm with potential for more than minimal harm that is not immediate jeopardy.
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 compliance with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiency to be an "F" level deficiency, widespread, with no harm but potential for more than minimal harm that is not immediate jeopardy. A plan of correction was required and remedies including denial of payments and possible termination of provider agreement were recommended if substantial compliance is not achieved.
Deficiencies (1)
The facility was cited with an "F" level deficiency that was widespread, indicating no harm but potential for more than minimal harm without immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed the enforcement letter regarding the Life Safety Code survey results. |
| Brenda McNorton | Director of Fire Prevention Division | Contact for Informal Dispute Resolution process. |
| Joe Ewert | Commissioner | Copied on the enforcement letter. |
Inspection Report
Re-Inspection
Deficiencies: 2
Date: Jun 16, 2014
Visit Reason
This visit was a follow-up to verify correction of previously reported deficiencies at the facility.
Findings
The report documents that previously cited deficiencies identified by regulation numbers 26-41-204 (c) and 26-41-104 (d) were corrected as of the revisit date.
Deficiencies (2)
Regulation 26-41-204 (c) deficiency was corrected by the revisit date.
Regulation 26-41-104 (d) deficiency was corrected by the revisit date.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jun 16, 2014
Visit Reason
This visit was a post-certification revisit to verify correction of previously cited deficiencies from the survey completed on 2014-05-29.
Findings
All previously cited deficiencies identified by regulation numbers F0279, F0280, F0309, F0323, F0329, and F0425 were corrected as of the revisit date.
Report Facts
Deficiencies corrected: 6
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Jun 16, 2014
Visit Reason
This is a revisit report to verify correction of previously reported deficiencies at the facility.
Findings
The report confirms that the previously cited deficiency with regulation 26-40-305 (c)(1)(2) has been corrected as of the revisit date.
Deficiencies (1)
Regulation 26-40-305 (c)(1)(2) deficiency was corrected by 2014-06-16.
Inspection Report
Re-Inspection
Deficiencies: 2
Date: Jun 16, 2014
Visit Reason
This visit was a follow-up to verify correction of previously reported deficiencies at the facility.
Findings
The report documents that previously cited deficiencies identified by regulation numbers 26-41-204 (c) and 26-41-104 (d) were corrected as of the revisit date.
Deficiencies (2)
Regulation 26-41-204 (c) deficiency was corrected by the revisit date of 2014-06-16.
Regulation 26-41-104 (d) deficiency was corrected by the revisit date of 2014-06-16.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jun 16, 2014
Visit Reason
This visit was conducted as a post-certification revisit to verify correction of previously cited deficiencies from the survey completed on 2014-05-29.
Findings
All previously reported deficiencies identified by regulation numbers F0279, F0280, F0309, F0323, F0329, and F0425 were corrected as of the revisit date.
Report Facts
Deficiencies corrected: 6
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Jun 16, 2014
Visit Reason
This is a revisit report to verify correction of previously reported deficiencies at the facility.
Findings
The report documents that the previously cited deficiency with regulation number 26-40-305 (c)(1)(2) was corrected as of 06/16/2014.
Deficiencies (1)
Regulation 26-40-305 (c)(1)(2) deficiency was corrected on 2014-06-16.
Inspection Report
Plan of Correction
Deficiencies: 7
Date: Jun 6, 2014
Visit Reason
This document is a Plan of Correction submitted by the facility to address previously cited deficiencies and outline corrective actions to achieve substantial compliance.
Findings
The plan details corrective actions for multiple deficiencies related to resident care plans, fall interventions, medication administration, and facility maintenance, with timelines for compliance and ongoing monitoring.
Deficiencies (7)
F279-D: Resident #65 discharged; care plans will be updated to include individualized interventions for constipation. Weekly audits will monitor compliance for 2 months.
F280-D: Resident #33 care plan revised to reflect fall interventions; care plans for residents with fall history will be reviewed weekly. Compliance monitored by audits for 2 months.
F309-D: Resident #65 discharged; bowel alerts reviewed daily to identify residents needing intervention for constipation. Weekly audits for 2 months will monitor compliance.
F323-D: Staff educated on fall interventions for resident #33; fall care plans reviewed for accuracy and communicated to staff. Weekly audits for 2 months will monitor compliance.
F329-D: Resident #65 discharged; education provided on PRN medication administration and monitoring. Random weekly audits of medication records for 2 months will ensure compliance.
F425-F: A 'Time' documentation box added to Medication Administration Record; staff educated on its use. Weekly audits for 2 months will monitor compliance.
S1354-E: Permanent exhaust fan installed in beauty shop; quarterly inspections will ensure continued service and maintenance.
Report Facts
Residents using beauty shop service: 15
Inspection Report
Re-Inspection
Census: 54
Deficiencies: 6
Date: May 29, 2014
Visit Reason
The inspection was a Health Resurvey to evaluate compliance with previously cited deficiencies and assess the facility's corrective actions.
Findings
The facility failed to develop comprehensive care plans addressing residents' specific needs, failed to revise care plans after falls, inadequately monitored and responded 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 ensuring proper medication administration timing.
Deficiencies (6)
F279: The facility failed to develop a comprehensive care plan addressing a resident's history of constipation to prevent fecal impaction.
F280: The facility failed to revise a resident's care plan after falls and did not implement new interventions to prevent further falls.
F309: The facility failed to monitor and respond effectively to a resident's constipation, resulting in fecal impaction.
F323: The facility failed to provide adequate supervision and implement assistive devices to prevent falls for a resident with Parkinson's disease and anxiety.
F329: The facility failed to consistently monitor the effectiveness of PRN medications used for constipation for one resident.
F425: The facility failed to have a pharmaceutical system that ensured medication doses were administered at least 4 hours apart to prevent doses being given too close together.
Report Facts
Facility census: 54
Sampled residents: 18
Falls risk scores: 10
Falls risk scores: 18
Falls risk scores: 20
Falls risk scores: 18
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative nurse A | Provided statements regarding care plan deficiencies and medication monitoring | |
| Administrative nurse B | Reported expectations for care plan revisions after falls and interventions | |
| Direct care staff C | Reported observations of resident behaviors and fall risks | |
| Direct care staff G | Reported resident's anxiety behaviors contributing to falls | |
| Direct care staff E | Reported on use of gray tray on wheelchair | |
| Licensed staff F | Reported family brought gray tray and lack of knowledge about its safety use | |
| Administrative Nurse A | Discussed medication administration timing and monitoring |
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 personal care was provided by certified nursing staff employed by the facility or an approved agency for one sampled resident. 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)
26-41-204(c)(1) The facility failed to ensure personal care provided to one resident was by certified nursing staff employed by the facility, a home health agency, or hospice. The resident's family hired a sitter who was not an employee of the facility or an approved agency.
26-41-104(d)(4) The facility failed to conduct and document an annual emergency drill with staff and residents that included evacuation to a secure location. The last documented drill was dated 9/18/12.
Report Facts
Facility census: 16
Sampled residents: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative nurse A | Interviewed regarding personal care provision and emergency drill documentation |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: May 29, 2014
Visit Reason
A Health survey was conducted to determine if the facility complies with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found a widespread 'F' level deficiency 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.
Deficiencies (1)
The facility had a widespread 'F' level deficiency constituting no actual harm but with potential for more than minimal harm that is not immediate jeopardy.
Inspection Report
Plan of Correction
Deficiencies: 2
Date: May 23, 2014
Visit Reason
The document is a Plan of Correction submitted in response to deficiencies identified during a prior inspection, including issues with private caregiver arrangements and disaster drill documentation.
Findings
The facility terminated a private caregiver arrangement to ensure all direct care staff are certified and employed by the facility or authorized agencies. The facility also conducted a disaster drill after missing documentation from the previous year and committed to ensuring annual drills and documentation are maintained.
Deficiencies (2)
S3160-D The facility terminated the private caregiver arrangement and will ensure all certified direct care staff are employed by the facility, a home health agency, or hospice. Compliance expected by 06/16/2014.
S3280-F The facility conducted a disaster drill on 05/23/2014 after missing 2013 documentation. The Assisted Living Director will ensure annual drills and documentation are completed and monitored. Compliance expected by 06/16/2014.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Mar 13, 2013
Visit Reason
This visit was a post-certification revisit to verify correction of previously cited deficiencies from the prior survey conducted on 2013-02-11.
Findings
The report confirms that all previously cited deficiencies identified by 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.
Report Facts
Deficiencies corrected: 4
Inspection Report
Follow-Up
Deficiencies: 0
Date: Mar 13, 2013
Visit Reason
This visit was a post-certification revisit to verify that previously identified deficiencies had been corrected as documented in the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
The report confirms that all previously cited deficiencies related to regulations 483.20(d), 483.20(k)(1), 483.25(i), 483.25(l), and 483.60(c) were corrected as of the revisit date.
Inspection Report
Re-Inspection
Census: 50
Deficiencies: 4
Date: Feb 11, 2013
Visit Reason
The visit was a health resurvey to assess compliance with previously cited deficiencies and to review the facility's corrective actions.
Findings
The facility failed to develop comprehensive care plans addressing nutritional risks for one resident, maintain nutritional status for another resident, and ensure drug regimens were free from unnecessary medications including proper monitoring and documentation of PRN medications. The pharmacist failed to identify irregularities and notify the director of nursing or physician regarding medication follow-up.
Deficiencies (4)
F279: The facility failed to develop a comprehensive care plan addressing nutritional risks for resident #67 who experienced significant weight loss.
F325: The facility failed to maintain acceptable nutritional status for resident #67 by not having a consultant assess continued weight loss or notify the consultant.
F329: The facility failed to ensure drug regimens were free from unnecessary drugs by not implementing non-pharmacological sleep interventions prior to hypnotic use and failing to document PRN medication administration and effectiveness.
F428: The pharmacist failed to review medication regimens adequately and did not notify the physician or director of nursing of irregularities related to PRN medication follow-up for residents #4, #43, and #46.
Report Facts
Facility census: 50
Residents sampled: 21
Residents sampled for unnecessary drug review: 10
Weight measurements: 197.8
Weight measurements: 191
Weight measurements: 186
Weight measurements: 180
Weight measurements: 177
Inspection Report
Plan of Correction
Deficiencies: 5
Date: Jan 20, 2013
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited in a prior inspection report (Event ID 2567). It outlines corrective actions to address identified issues and maintain compliance.
Findings
The facility plans to improve quality assurance efforts, update care plans for residents at nutritional risk, ensure dietician consultations for residents with weight loss, review medication regimens, and enhance monitoring of PRN medication administration and pharmacist audits.
Deficiencies (5)
F0000: The facility will adjust Quality Assurance efforts to maintain substantial compliance with participation requirements and provide documentation to the QA committee.
F279-D: The MDS Coordinator will update care plans for residents at nutritional risk or with weight loss, with weekly interdisciplinary team reviews and random audits to ensure compliance.
F325-D: Residents at nutritional risk will be referred to a dietician for consultation upon admission and during stay, with ongoing monitoring and updated lists maintained by DON, ADON, and Dietary manager.
F329-D: Medication regimens for specified residents will be reviewed by physicians; staff will receive education on PRN medication administration and monitoring, with audits conducted thrice weekly.
F428-D: Consultant pharmacist will audit medication administration records monthly to identify irregularities and report findings for follow-up and QA review.
Report Facts
Complete Date: Jan 20, 2013
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N087012 POC G03B11
Visit Reason
This document is a plan of correction related to a prior deficiency report for the facility Medicalodge of Goddard.
Findings
No specific findings or deficiencies are detailed in this document. It serves as a record of the plan of correction submission and modification dates.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N087012 POC
Visit Reason
This document is a Plan of Correction related to a facility identified by State ID N087012, intended to address deficiencies noted in a prior inspection.
Findings
No deficiency records or details are found in this Plan of Correction document.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N087012 POC 1B0N11
Visit Reason
This document is a Plan of Correction related to a prior inspection event for the facility identified as ASPEN with State ID N087012.
Findings
No deficiency records or findings are included in this Plan of Correction document.
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, improper chemical and equipment storage, medication administration errors, expired medications, wound care procedures, and dietary management qualifications. Corrective actions and staff education were planned with target completion dates.
Deficiencies (6)
F253-E Cove bases, floor tiles, and door frames in residents' rooms require auditing and repair or replacement as needed. The wallpaper in the dining area will also be repaired and monitored monthly.
F323-E Facility staff were educated on proper chemical storage, equipment storage, and door alarm procedures. Daily audits and inspections will ensure compliance and hazard-free hallways.
F425-D Resident #75's medication administration record was reviewed; physician was notified of missed medications. Staff were re-educated on medication administration and reordering procedures with ongoing weekly audits planned.
F431-D All medications were checked for expiration. Licensed nurses were educated on proper insulin storage and disposal of insulin pens with ongoing weekly audits planned.
F441-D Resident #39's wound remains free of infection. Licensed nursing staff were educated on clean dressing change procedures with ongoing monitoring and audits.
S0600-C Dietary manager is enrolled in dietary classes and will test for CDM certification by December 2015. The administrator and HR will monitor progress.
Report Facts
Plan of Correction completion dates: Oct 15, 2015
Plan of Correction completion dates: Oct 22, 2015
Plan of Correction completion dates: Oct 2, 2015
Plan of Correction completion dates: Oct 4, 2015
Plan of Correction completion dates: Dec 24, 2015
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N087012 POC XG8F11
Visit Reason
This document is a Plan of Correction related to a prior inspection event for the facility.
Findings
No specific findings or deficiencies are detailed in this document. It serves as a placeholder or administrative record for the Plan of Correction.
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