Medicalodges Fort Scott

Inspectors wroteThe facility reported a census of 33 residents. Based on observation, interview, and record review, the facility failed to conduct annual performance reviews for two of the five direct care staff reviewed.

Inspectors wroteThe facility identified a census of 33 residents. The sample included 14 residents. Based on observation, interviews and record review, the facility failed to maintain a clean, homelike environment

Inspectors wroteThe facility reported a census of 33 residents. Thirty medications administrations were observed with two medications errors identified resulting in a medications error rate of 6.67 percent. Based on observation, interview, and record review, the facility failed to ensure a medication error rates of five percent or less. - Resident (R)39's Physician Orders (POS) revealed orders for the following morning medication administration: Phenazopyridine HCL 200 milligrams (mg), by mouth, three times a day, after meals, ordered 02/13/26 Protonic oral tablet, 40 mg, delayed release tablet, give twice a day, 30 minutes to one-hour before meals. On 02/17/26 at 09:00 AM, Certified Medication Aide (CMA) R prepared the R39's medications. The phenazopyridine HCL 200 mg was omitted. [...]

Inspectors wroteThe facility had a census of 33 residents. The sample included 14 residents with one reviewed for hospitalization. Based on interviews and record review, the facility failed to provide a written bed hold policy including duration for Resident (R) 2.

Inspectors wroteThe facility identified a census of 33 residents. The sample included 13 residents. Based on record review and interview, the facility failed to complete a Significant Change Minimum Data Set (MDS) after identifying a decline in Resident (R) 1's status resulting in initiation of hospice services.

Inspectors wroteThe facility reported a census of 33 residents; the sample included 14 with five residents reviewed for unnecessary medications and related monitoring. Based on observation, interview, and record review revealed the facility failed to monitor and respond to Resident (R) 2's lack of bowel movements.

Inspectors wroteThe facility identified a census of 33 residents. The sample included 14 residents, with five residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to ensure the Consultant Pharmacist (CP) recommendations were reviewed and addressed by the physician for Resident (R) 23 and R2.

Inspectors wroteThe facility identified a census of 33 residents. The sample included 14 residents, with five residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 23's thyroid (organ at the front of the neck that secretes hormones) hormone levels were monitored to determine the effectiveness of his ordered thyroid hormone replacement medication.

Inspectors wroteThe facility reported a census of 34 residents. Based on observation, interview, and record review, the facility failed to ensure an accurate and adequate system for monitoring and reconciliation of narcotic medications in the facility emergency kits (e-kit), putting the residents at risk of misappropriation of medications.

Inspectors wroteThe facility reported a census of 34 residents. The sample included three residents. Based on observation, interview, and record review the facility failed to provide protective measures for Resident (R)1 following an allegation of abuse. This placed the resident at risk for abuse.

Inspectors wroteThe facility reported a census of 34 residents. The sample included three residents. Based on observation, interview, and record review the facility failed to update Resident (R) 1's Care Plan, putting the resident at risk for inadequate care due to uncommunicated care needs.

Inspectors wroteThe facility reported a census of 26. The sample included three residents reviewed for neglect. Based on observations, record review, and interview, the facility failed to ensure dependent and cognitively impaired Resident (R) 1, who had a diagnosis of dysphagia (swallowing difficulty), oropharyngeal phage (delay in swallowing), and ileus (obstruction of the intestines [gastrointestinal tract that absorbs nutrients and water from food], caused by immobility of the bowel), remain free from neglect when Certified Medication Aide (CMA) S continued to administer R1's morning medications despite R1's request to slow down because she was having a difficult time swallowing. When CMA S left the room, CMA S told R1 there you're done now you can quit your crying.

Inspectors wroteThe facility reported a census of 26. The sample included three residents reviewed for neglect. Based on observations, record review, and interview, the facility failed to ensure dependent and cognitively impaired Resident (R) 1, who had a diagnosis of dysphagia (swallowing difficulty), oropharyngeal phage (delay in swallowing), ileus (obstruction of the intestines [gastrointestinal tract that absorbs nutrients and water from food], caused by immobility of the bowel), remain from neglect when Housekeeping U and Outside Resource Staff EE failed to report to Administrative Staff A that Certified Medication Aide S continued to administer R1's morning medications despite R1's request to slow down because she was had a difficult time swallowing. When CMA S left the room, CMA S told R1 there you're done now you can quit your crying.

Inspectors wroteThe facility identified a census of 37 residents. The sample included 12 residents. Based on interview and record review, the facility failed to ensure adequate staffing levels on the weekends to meet the needs of the residents. This placed the residents at risk for impaired mental and physical well-being.

Inspectors wroteThe facility had a census of 37 residents. The sample included 12 residents and five Certified Nurse Aides (CNA) reviewed for performance evaluations and the associated in-service training. Based on record review and interview, the facility failed to ensure five of the five CNA staff reviewed had the required yearly performance evaluations completed. This placed the residents at risk for inadequate care.

Inspectors wroteThe facility had a census of 37 residents. The sample included 12 residents and five Certified Nurse Aides (CNAs) reviewed for 12 hours of required in-service training. Based on record review and interview, the facility failed to ensure five of the five CNA staff reviewed had the required 12 hours of in-service education. This placed the residents at risk for inadequate care.

Inspectors wroteThe facility identified a census of 37 residents. The sample included 12 residents. Based on record review, observation, and interviews, the facility failed to post the State Survey Agency (SSA) contact information on how to report abuse in a manner accessible to the residents and their representatives. This deficient practice placed the residents at risk for ongoing abuse and other concerns. Findings Included: - On 04/01/24 at 07:20 AM a walkthrough of the facility was completed. Upon inspection of the facility's television area, a small 8-inch by 10-inch (8x10) poster with small black writing was posted by the main entry door to the room four feet high on the wall. The poster displayed the SSA contact information and instructions related to reporting complaints related to abuse. [...]

Inspectors wroteThe facility identified a census of 37 residents. The sample included 12 residents. Based on observation, record review, and interviews, the facility failed to implement a system to allow residents and/or their representatives to file grievances anonymously. This deficient practice placed the residents at risk for decreased psychosocial well-being and unresolved grievances and concerns. Findings Included: - On 04/02/24 at 08:00 AM an inspection of the facility revealed no designated grievance drop boxes or system available in the areas accessible to the residents and visitors of the facility. On 04/02/24 at 10:15 AM, the Resident Council members reported they were not aware if the facility provided a way to complete anonymous grievances. The council reported Administrative Staff A was responsible for complaints and grievances. [...]

Inspectors wroteThe facility identified a census of 37 residents. The sample included 12 residents. Based on observation, interview, and record review the facility failed to review and revise the care plan with resident-specific interventions for Resident (R)7, R10, R25, and R14. This deficient practice placed the residents at risk for impaired care due to uncommunicated care needs. Findings Included: - The Medical Diagnosis section within R7's Electronic Medical Records (EMR) included diagnoses of morbid obesity (severely overweight), chronic obstructive pulmonary disorder (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), muscle weakness, and respiratory failure. [...]

Inspectors wroteThe facility identified a census of 37 residents. The sample includes 12 residents. Based on observation, record review, and interviews, the facility failed to provide consistent weekend activities. This deficient practice placed the affected residents at risk for decreased psychosocial well-being.

Inspectors wroteThe facility had a census of 37 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to ensure a safe environment free from hazardous materials for eight cognitively impaired independently mobile residents. The facility additionally failed to assess and ensure Resident (R) 25's siderails were mounted safely. This deficient practice placed the affected residents at risk for preventable accidents. Findings Included: - On 04/01/24 at 07:05 AM a walkthrough of the facility was completed. An inspection of the facility's east hallway revealed an unlocked oxygen storage room. An inspection of the room revealed 25 pressurized supplemental oxygen cylinders stored on the racks. The room contained eight smaller pressurized cylinders underneath a shelf. [...]

Inspectors wroteThe facility identified a census of 37 residents. The sample included 12 residents. Based on record review, observations, and interviews, the facility failed to ensure adequate infection control standards related to following enhanced barrier precautions (EBP-infection control interventions designed to reduce transmission of resistant organisms which employs targeted gown and glove use during high contact care), laundry services, and sanitary care practices. his deficient practice placed the residents at risk for infectious diseases. Findings Included: - The facility identified it was completing ongoing exposure testing for COVID-19 (highly contagious, potentially life-threatening respiratory virus) but had no COVID-19-positive residents in the facility. [...]

Inspectors wroteThe facility identified a census of 37 residents. The sample included 12 residents. Based on records review, interviews, and observations, the facility failed to provide effective pest control so that the facility was free from pests. This placed the residents at increased risk for impaired comfort and disease. Finding Included: - An inspection of the facility's Pest Siting log indicated that cockroaches were last seen in the facility on 07/07/23 around the north hall soiled utility room. The pest control log indicated the facility contracted a company to spray monthly. The log indicated the last pest control treatment was in March 2024. On 04/01/24 at 07:01 AM a walkthrough of the facility was completed. [...]

Inspectors wroteThe facility identified a census of 37 residents with 12 residents included in the sample. The facility identified six residents who were discharged from Medicare Part A services. Based on interview and record review the facility failed to issue CMS (Center for Medicare/Medicaid Services) Notification of Medicare Non-Coverage Form 10123 (NOMNC- the form used to notify Medicare A participants of their rights to appeal and the last covered date of participants of potential financial liability when a Medicare Part A episode ends) with the required information for Resident (R) 88 and R 89. This failure placed the residents at risk for decreased autonomy and impaired decision-making.

Inspectors wroteThe facility identified a census of 37 residents. The sample included 12 residents with two residents reviewed for hospitalization. Based on observation, record review, and interviews, the facility failed to provide written notice of transfer or discharge notice for Resident (R) 10's facility-initiated transfers. This deficient practice placed R10 at risk of uninformed choices and miscommunication regarding care needs.

Inspectors wroteThe facility identified a census of 37 residents. The sample included 12 residents with two residents reviewed for hospitalization. Based on observation, record review, and interviews, the facility failed to provide a bed hold notice when Resident (R) 10 was hospitalized . This deficient practice placed R10 at risk of uninformed choices.

Inspectors wroteThe facility identified a census of 37 residents. The sample included 12 residents with three residents reviewed for activities of daily living (ADL). Based on record review, and interviews, the facility failed to ensure Resident (R) 25 received the necessary ADL assistance he required for his hearing aids. This deficient practice placed R25 at risk for the inability to communicate with peers or staff, increased confusion, negative psychosocial outcomes, and decreased dignity.

Inspectors wroteThe facility identified a census of 37 residents. The sample included 12 residents with one resident reviewed for quality of care. Based on observation, record review, and interviews, the facility failed to follow a physician's order for daily weights to monitor for fluid overload for Resident (R) 14. This deficient practice placed R14 at risk for delay in treatment related to fluid overload and untreated illness.

Inspectors wroteThe facility identified a census of 37 residents. The sample included 12 with five reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). Based on interviews, observations, and record reviews, the facility failed to ensure Resident (R)7's pressure-reducing interventions were implemented correctly when his low air-loss mattress pump was inappropriately set for his current weight. This deficient practice placed the resident at risk for complications related to skin breakdown and pressure ulcers. Findings Included: [...]

Inspectors wroteThe facility identified a census of 37 residents. The sample included 12 residents with one resident reviewed for positioning and mobility. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 10 was provided services and treatment to prevent worsening of contractures (abnormal permanent fixation of a joint or muscle) in his left hand. This deficient practice placed R10 at risk for discomfort and decreased range of motion (ROM- the full movement potential of a joint, usually its range of flexion and extension).

Inspectors wroteThe facility identified a census of 37 residents. The sample included 12 residents with two residents reviewed for catheters (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid) and urinary tract infections (UTI infection in any part of the urinary system). Based on observation, record review, and interviews, the facility failed to ensure Resident (R)2 received sanitary catheter care when staff failed to provide R2 education on performing sanitary catheter care and failed to assess R2's ability to self-perform her catheter care. These deficient practices placed the resident at risk for catheter-related complications.

Inspectors wroteThe facility identified a census of 37 residents. The sample included 12 residents with two reviewed for nutrition. Based on record review, observations, and interviews, the facility failed to obtain accurate weights as ordered by the medical provider to prevent avoidable weight loss for Resident (R)4. This deficient practice placed R4 at risk for complications related to weight loss. Findings Included: - The Medical Diagnosis section within R4's Electronic Medical Records (EMR) included diagnoses of cognitive communication deficit, dysphagia (difficulty swallowing), chronic obstructive pulmonary disorder (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), muscle weakness, and abnormal weight loss. [...]

Inspectors wroteThe facility identified a census of 37 residents. The sample included 12 residents with two residents reviewed for respiratory care. Based on observation, record review, and interviews, the facility failed to ensure appropriate respiratory care and services for Resident (R)33 and R2. This placed the residents at risk for respiratory complications.

Inspectors wroteThe facility identified a census of 37 residents. The sample included 12 residents with one resident reviewed for siderails. Based on observation, record review, and interview, the facility failed to ensure that Resident (R) 25 had documented consent for the use of the siderails, failed to show alternative methods were attempted, and failed to ensure the resident and/or responsible party were advised of the risks and/or benefits of the use of the siderails. This placed the resident and/or representative at risk for uninformed decisions related to the risks and benefits associated with the use of siderails.

Inspectors wroteThe facility identified a census of 37 residents. The sample included 12 with one reviewed for significant medication errors. Based on interviews and record reviews, the facility failed to ensure staff possessed the appropriate skills and knowledge to administer Resident (R)30's Midodrine (medication used to increase blood pressure). This deficient practice placed R30 at risk for impaired quality of care. Findings Included: - The Medical Diagnosis section within R30's Electronic Medical Records (EMR) included diagnoses of hypotension (low blood pressure), muscle weakness, major depressive disorder (major mood disorder), and aphasia (condition with disordered or absent language function). R30's admission Minimum Data Assessment (MDS) completed 03/15/24 noted a Brief Interview for Mental Status (BIMS) assessment was not completed due to severe impairment. [...]

Inspectors wroteThe facility identified a census of 37 residents. The sample included 12 residents. with six residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported the need for physician documented rationale for the continued use of the antipsychotic medication for Resident (R) 3 who had a diagnosis of dementia (a progressive mental disorder characterized by failing memory, and confusion). The facility also failed to follow the recommendations of the CP related to R30's Midodrine administration given outside of the physician-provided parameters repeatedly. This deficient practice placed R30 at risk for adverse medication effects.

Inspectors wroteThe facility identified a census of 37 residents. The sample included 12 residents with five residents reviewed for unnecessary medication. Based on observation, record review, and interviews, the facility failed to provide adequate pulse monitoring for Resident (R)4's anti-hypertensive beta-blocker (class of medication used to treat high blood pressure). The facility additionally failed to obtain physician-ordered lab results for R3's medication regimen. These deficient practices placed the residents at risk for unnecessary medications and adverse medication effects. Findings Included: [...]

Inspectors wroteThe facility identified a census of 37 residents. The sample included 12 residents with five residents reviewed for unnecessary medications. Based on observation, record review, and interview the facility failed to ensure an appropriate indication, or a documented physician rationale which included the multiple unsuccessful attempts for nonpharmacological symptom management and risk versus benefits for the continued use of an antipsychotic (class of medications used to treat mental disorder characterized by a gross impairment in reality testing) for Resident (R)3's olanzapine (antipsychotic medication). This placed the resident at risk for unnecessary psychotropic (alters perception, mood, consciousness, cognition, or behavior) medications and related complications.

Inspectors wroteThe facility identified a census of 37 residents. The sample included 12 with one reviewed for significant medication errors. Based on interviews and record reviews, the facility failed to prevent a significant medication error for Resident (R)30 when staff administered Midodrine (medication used to increase blood pressure) outside of the physician-provided parameters repeatedly. This deficient practice placed R30 at risk for adverse medication effects. Findings Included: - The Medical Diagnosis section within R30's Electronic Medical Records (EMR) included diagnoses of hypotension (low blood pressure), muscle weakness, major depressive disorder (major mood disorder), and aphasia (condition with disordered or absent language function). [...]

Inspectors wroteThe facility identified a census of 37 residents. The sample included 12 residents. Based on observation, record review, and interviews, the facility failed to ensure a communication process was implemented, which included how the communication would be documented between the facility and the hospice provider, and a failed to describe the services and equipment provided to Resident (R) 25 by hospice. This deficient practice created a risk for missed or delayed services and impaired care for R25.

Inspectors wroteThe facility identified a census of 37 residents. The sample included 12 residents with five reviewed for pneumococcal (type of bacterial infection), and influenza (highly contagious viral infection immunizations. Based on record review and interviews, the facility failed to provide consent, declination, or documentation of ineligibility for Resident (R)2, R19, and R33's pneumococcal vaccinations. This deficient practice placed the residents at risk for complications related to pneumococcal diseases. Findings Included: - On 04/02/24 at 10:03 AM a review was completed related to pneumococcal and influenza vaccinations for R2, R7, R19, and R33. R2's Electronic Medical Record (EMR) indicated she was admitted to the facility on [DATE]. The EMR indicated she refused the Prevnar 13 (07/2017) and Pneumovax 23 (09/2018) vaccinations. [...]

Inspectors wroteThe facility identified a census of 37 residents. The sample included 12 residents with five reviewed for COVID-19 (highly contagious viral infection) immunizations. Based on record review and interviews, the facility failed to provide consent, declination, or documentation of ineligibility for Resident (R)3's COVID-19 immunizations. This deficient practice placed the residents at risk for complications related to COVID-19. Findings Included: - On 04/02/24 at 10:03AM a review was completed related to COVID-19 immunization for R2, R3, R7, R19, and R33. R3's EMR indicated she was admitted to the facility on [DATE]. The EMR lacked documentation indicating she received or was offered COVID-19 immunizations. The EMR indicated she had no COVID-19 vaccinations. The EMR lacked consent, declination, or documentation of ineligibility for her COVID-19 vaccinations. [...]

Inspectors wroteThe facility identified a census of 37 residents. The sample included 12 residents. Based on observation, record review, and interviews, the facility failed to ensure the residents received their mail services on Saturdays. Findings Included: - On 04/02/24 at 10:15 AM, Resident Council members reported that the facility does not provide mail services for the residents on Saturdays. The council reported they receive mail Monday through Friday, but there is no one to pick up and pass mail on Saturdays. On 04/03/2 at 10:31 AM Activities Coordinator (AC) Z reported that she would get the mail if Administrative Staff A was not going to be at the facility on Monday through Friday. AC Z stated there was no one at the facility to pick up the resident's mail on Saturdays. [...]

Inspectors wroteThe facility identified a census of 37 residents. The sample included 12 residents. Based on interviews and observations, the facility failed to post the previous state inspection information in a location accessible to the residents and visitors. Findings Include: - On 04/01/24 at 07:10 AM an initial walkthrough of the facility revealed a sign posted Survey Results in the main lobby with an arrow pointing down to the ground. An inspection of the ground and surrounding area revealed no previous survey results. On 04/02/24 at 10:15 AM the resident council reported they were unaware of where the survey book was located. The council reported a sign in the main lobby behind a recliner but not sure where the book was located. On 04/03/24 at 11:00 AM an inspection of the facility revealed no posted survey results accessible to the residents or their representatives. [...]

Inspectors wroteThe facility identified a census of 37 residents. Based on observation, record review, and interviews, the facility failed to retain the daily posted nursing staffing data for the 18 months as required.

Inspectors wroteThe facility reported a census of 50 residents. Based on observation, interview and record review, the facility failed to ensure an effective infection control and prevention program to prevent the spread of infection.

Inspectors wroteThe facility reported a census of 50 residents. Based on record review and interview, the facility failed to ensure nursing staff followed the principles of antibiotic stewardship in a proactive manner to ensure residents received antibiotics in a safe and effective manner to prevent unnecessary side effects of antibiotics and antibiotic resistance. The facility failed to track and trend causative microorganisms to determine trends within the facility.

Inspectors wroteThe facility reported a census of 50 residents. The sampled of 16 residents included eight reviewed for Covid-19 vaccinations. Based on interview and record review, the facility failed to ensure eight of the eight sampled residents were offered the second vaccine booster which became available on May 20, 2022 in a timely manner as required and/or failed to monitor the residents' vaccine status for possible booster administration.

Inspectors wroteThe facility reported a census of 50 residents. Based on observation, record review and interview, the facility failed to provide housekeeping and maintenance services to maintain a sanitary, orderly environment in the storage closets that contained supplies for the residents of the facility.

Inspectors wroteThe facility reported a census of 50 residents. Based on observation, record review and interview, the facility failed to provide housekeeping and maintenance services to maintain a sanitary, orderly, and comfortable interior for residents in the facility.

Inspectors wrote- Review of Resident (R)24's electronic medical record (EMR), under the Med (Medical) Diag (diagnosis) tab, included a diagnosis of Parkinson's disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness). The admission Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of eight, indicating moderately impaired cognition. She required extensive assistance of two staff for transfers and had no limitation in range of motion (ROM). The Activities of Daily Living (ADL) Functional/Rehabilitation Potential Care Area Assessment (CAA), dated 04/24/22, documented the resident was able to make her needs known. She required extensive assistance of staff for transfers. [...]

Inspectors wroteThe facility reported a census of 50 residents with 16 residents sampled, including three residents reviewed for Activities of Daily Living (ADL). Based on interview, record review and observation, the facility failed to ensure two Residents (R)21, and R 25, received appropriate personal hygiene, regarding facial shaving.

Inspectors wroteThe facility reported a census of 50 residents with 16 residents selected for review, which included two residents reviewed for pressure ulcers. Based on observation, interview and record review, the facility failed to ensure one of the two selected Residents (R) 13, received appropriate monitoring and treatment and preventive measures for pressure ulcers.

Inspectors wroteThe facility reported a census of 50 residents with 16 residents sampled, including four residents reviewed for accidents. Based on interview, record review, and observation, the facility failed to ensure staff provided safe transfers for one Resident (R)24, of the four residents reviewed for accidents.

Inspectors wroteThe facility reported a census of 50 resident with 16 selected for review which included two residents reviewed for urinary catheter. Based on observation, interview and record review, the facility failed to ensure sanitary catheter care for one of two residents (R) 12, reviewed for catheter care.

Inspectors wroteThe facility reported a census of 50 residents. The sample of 16 residents included two residents which received their total nutrition and hydration through a percutaneous enteral gastrostomy feeding tube, (PEG- a tube that directly enters the stomach through the abdominal wall). Based on observations, interviews, and record review, the facility failed to ensure one Resident (R)19 received appropriate treatment and services to prevent potential complications and/or metabolic interactions related to the resident's tube feeding and mixture of his medications through his PEG tube.

Inspectors wroteThe facility reported a census of 50 residents, which included one resident sampled for respiratory care. Based on observation, interview, and record review, the facility failed to provide appropriate respiratory care in maintaining respiratory equipment to prevent the spread of infection, consistent with standards of practice and person -centered care plan for one Resident (R)19, related to storage and tubing/mask change of oxygen equipment.

Inspectors wroteThe facility reported a census of 50 residents with 16 selected for review which included five residents reviewed for unnecessary medications. Based on observation, interview and record review, the facility failed to ensure staff monitor bowel movements and administer laxatives for two of the five Residents (R) 3 and R21. Furthermore, the facility failed to obtain laboratory results to monitor the effectiveness of medications for one of the five residents, R22.