Medicalodges Goddard

Inspectors wroteThe facility reported a census of 45 residents. Based on interview and record review, the facility failed to develop, implement, and permanently maintain an in-service training program for Certified Nurse Aide (CNAs) with the required topics and no less than 12 hours per year. Two of the five nurse aides sampled lacked the required training topics. Two of five nurse aides sampled lacked the required 12 hours per year of in-service training.

Inspectors wroteThe facility reported a census of 45 residents. Five staff were reviewed for background checks. Based on interview and record review, the facility failed to implement their policy when facility failed to ensure background checks were completed for one staff.

Inspectors wroteThe facility had a census of 45 residents; the sample included 13 residents. Twenty-nine medications administrations were observed with three errors identified resulting in a medication error rate of 10.34 %. Based on observation, record review, and interview, the facility failed to ensure a medication error rate below five percent.

Inspectors wroteThe facility reported a census of 45 residents. The sample included 13 residents with four residents reviewed for accident. Based on observation, interview and record review, the facility failed to clean reusable shared equipment between residents and failed to use proper Enhanced Barrier Precautions (EBP-infection control interventions designed to reduce transmission of resistant organisms which employ targeted gown and glove use during high contact care) for R1 who had an indwelling catheter (tube placed in the bladder to drain urine into a collection bag) and wounds.

Inspectors wroteThe facility reported a census of 45 residents; the sample included 13 residents. Based on interview, observation, and record review, the facility failed to protect the dignity of Resident (R) 33 when staff was argumentative and used foul language while speaking to R33.

Inspectors wroteThe facility reported a census of 45 residents; the sample included 13 residents. Based on interview, observation, and record review, the facility failed to inform Resident (R) 18 and/or his representative regarding the risks related to psychotropic (alters mood or thoughts) medications.

Inspectors wroteThe facility had a census of 45 residents. The sample included 13 residents with two residents reviewed for hospitalization. Based on interview and record review, the facility failed to provide a bed hold and written notification of transfer for Resident (R) 49 and failed to provide written notification of transfer for R33. The facility additionally failed to notify the Office of the Long-Term Care Ombudsman (LTCO).

Inspectors wroteThe facility identified a census of 45. The sample included 13 residents with one resident reviewed for mobility or range of motion (ROM - the full movement potential of a joint, usually its range of flexion and extension). Based on observation, record review, and interviews, the facility failed to implement an assistive program to help maintain ROM and prevent a potential decrease in ROM/mobility for Resident (R) 22.

Inspectors wroteThe facility reported a census of 45 residents; the sample included three residents reviewed for accidents. Based on observation, interview, and record review, the facility failed to follow an intervention to prevent further falls after a fall for Resident (R) 6. This placed the residents at risk for further falls and related injuries.

Inspectors wroteThe facility identified a census of 45 residents. The sample included 13 residents with three sampled for nutrition. Based on observation, interview and record review, the facility failed to promote Resident (R) 3's highest practicable nutritional status when staff failed to weigh the resident upon admission and readmission after hospitals stays in order to establish a baseline and/or identify weight loss.

Inspectors wroteThe facility reported a census of 45 residents. Based on observation, interview, and record review, the facility failed to ensure the posted daily nurse staffing sheets included accurate and identifiable information to include actual staff hours, as required.

Inspectors wroteThe facility reported a census of 44 residents with three residents included in the sample. Based on observation, interview, and record review the facility failed to ensure an environment free of accident hazards on 01/14/25 when Certified Nurse Aide (CNA) M did not follow the standard of care and utilize another staff member assistance during the transfer of Resident (R) 1 from his wheelchair to his bed, using a Hoyer Lift (a mechanical device that helps people with limited mobility be transferred safely with minimal physical effort).

Inspectors wroteThe facility reported a census of 43 with 3 residents selected for review. Based on observation, interview, and record review, the facility failed to implement infection control measurements by the failure to cleansing hands between glove changes during a wound dressing change on Resident (R) 2.

Inspectors wroteThe facility reported a census of 38 residents. Based on observation, interview, and record review, the facility failed to store Controlled Medications (medications which fall under US Drug Enforcement Agency (DEA) Schedules II-V), have a potential for abuse, ranging from low to high, and may also lead to physical or psychological dependence), permitting only authorized personnel to have access related to diversion of controlled medication for three residents. Resident (R)145 for unknown quantity of Lorazepam, 0.5 milligram(mg) tablets (anti-anxiety medication), R 146 for unknown quantity of Oxycodone 10/325 mg. tablets (a narcotic/pain medication), and R 147 for unknown quantity of Lorazepam. [...]

Inspectors wroteThe facility reported a census of 38 residents. Based on interview and record review, the facility failed to electronically submit to Centers for Medicare and Medicaid Services, (CMS) complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS (i.e., Payroll Base Journal [PBJ]), related to weekend staffing data is excessively low.

Inspectors wroteThe facility reported a census of 38 residents with 13 residents sampled. Based on observation, interview, and record review, the facility failed to maintain an effective infection control program with the failure of staff to follow infection control standards when delivering laundry to resident rooms and failure to follow the standard of practice when performing a partial bed bath to Resident (R) 195's perineum (the area of skin between the anus and the genitals). This deficient practice has the potential to lead to cross contamination between residents, and to place the residents receiving bed baths at increased risk of developing infections.

Inspectors wroteThe facility reported a census of 38 residents. Based on observation, interview, and record review the facility failed to ensure a safe sanitary environment for the residents and staff in the facility laundry.

Inspectors wroteThe facility had a census of 38 residents. Based on observation, record review, and interview, the facility failed to maintain a clean, comfortable and homelike environment to the residents that resided in the facility.

Inspectors wroteThe facility reported a census of 38 residents with 13 residents sampled, that included five residents selected for review related to dignity. Based on interview, observation, and record review, the facility failed to protect the privacy and dignity of Residents (R)40 and R95. This deficient practice led to R40's and R95's respective urinary catheter (a tube inserted into the bladder to drain urine and into a collection bag) bags to be visible to visitors and other residents. This practice had the potential to lead to negative psychosocial effects related to dignity.

Inspectors wroteThe facility reported a census of 38 residents with 13 residents selected for review. Based on observation, interview, and record review, the facility failed to accurately complete the Minimum Data Set (MDS) for one sampled resident, Resident (R)195, related to the use of indwelling urinary catheter (a tube inserted into the bladder to drain urine into a collection bag). This placed the resident at risk for uncommunicated care needs.

Inspectors wroteThe facility identified a census of 38 residents, with 13 residents selected for review. Based on observation, record review and interview, the facility failed to develop a comprehensive person-centered care plan for Resident (R)39, regarding the need for isolation.

Inspectors wroteThe facility reported a census of 38 residents. The sample included 13 residents. Based on observation, interview and record review, the facility failed to review and revise one resident's care plans, related to adequate monitoring and care of Resident (R)26's multiple skin areas/wounds.

Inspectors wroteThe facility reported a census of 38 residents. The sample included 13 residents with one resident sampled for skin condition, not related to pressure ulcer/injury. Based on observation, interview and record review, the facility failed to ensure adequate monitoring of one Resident (R)26's skin condition, to ensure resolution of multiple skin areas/wounds (20).

Inspectors wroteThe facility reported a census of 38 residents with 13 residents sampled, that included two reviewed for urinary catheter (a tube inserted into the bladder to drain urine into a collection bag) care. Based on interview, observation, and record review, the facility failed to provide appropriate treatment and services of Resident (R)95 when resident was transported with the urinary collection bag above the level of his bladder. This deficient practice had the potential to negatively affect R95.

Inspectors wroteThe facility reported a census of 38 residents. Based on interview and record review, the facility failed to conduct annual performance reviews for one of the two Certified Nurse Aides that the facility had employed over a year.

Inspectors wroteThe facility reported a census of 38 residents with 13 residents sampled, that included two reviewed for urinary catheter (a tube inserted into the bladder to drain urine into a collection bag) care. Based on interview, observation, and record review, the facility failed to provide appropriate treatment and services of Resident (R)195 from lack of documented catheter care. This deficient practice had the potential to negatively affect R195.

Inspectors wroteThe facility reported a census of 38 residents. Based on interview and record review, the facility failed to ensure no less than 12 hours per year required in-service training to ensure the continuing competence of nurse aides for one of the two nurse aides employed for a year or more.

Inspectors wroteThe facility census totaled 49 residents, with three residents reviewed for elopement (an incident in which a cognitively impaired resident with poor or impaired decision-making ability/safety awareness leaves the facility without the knowledge of staff). Based on observation, interview, and record review the facility failed to ensure a safe/secure environment for cognitively impaired, independently mobile Resident (R) 1, with a known history of exit seeking, to prevent him from leaving the facility on [DATE] at around 08:00 PM. The facility failed to ensure all staff working were trained in elopement procedures, failed to have an effective system in checking the wandering alarm system for functionality at the exit door, and did not provide adequate supervision for R1. [...]

Inspectors wroteThe facility reported a census of 46 residents, with 12 sampled. Based on observation, interview, and record review, the facility failed to complete a comprehensive, accurate, standardized reproducible assessment within 14 calendar days after admission for Resident (R) 92.

Inspectors wroteThe facility census totaled 46 residents with 12 included in the sample. Based on observation, interview and record review the facility failed to revise the comprehensive care plan when Resident (R)20 readmitted to the facility to include oxygen use.

Inspectors wroteThe facility had a census of 46 residents with 12 included in the sample. Based on observation, interview and record review the facility failed to provide bathing and grooming for three residents reviewed for bathing, as evidenced by lack of documentation on the bath record, long facial hair and dirty and long fingernails for Resident (R)25, R26, and R27.

Inspectors wroteThe facility reported a census of 46 residents with 12 included in the sample. Based on observation, interview, and record review the facility failed to ensure they had a system in place to change oxygen tubing, nebulizer tubing and cleaning of respiratory equipment in a timely manner for Residents (R) 20 and R92.

Inspectors wroteThe facility reported a census of 46 residents. Based on observation, interview, and record review the facility failed to ensure a safe sanitary environment to prevent infection for Resident (R) 92, by not storing his oxygen mask, nebulizer (device which changes liquid medication into a mist easily inhaled into the lungs) mask, and urinary catheter (insertion of a catheter into the bladder to drain the urine into a collection bag) drainage bag in a sanitary manner. Findings Included: - An observation on 05/09/22 at 04:54 PM R92 laid in bed on his back with the head of the bed elevated. R92's oxygen (O2) mask laid on the floor and still had O2 flowing through it. R92's urinary catheter drainage bag also laid on the floor under the bed. On 05/10/22 at 01:09 PM R92's O2 mask laid on the mattress next to him with no barrier noted between the mask and the mattress. [...]