Medicalodges Neosho

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect the resident's right to be free from sexual abuse by other residents when one resident (Resident #1) exhibited abusive behaviors including touching breasts of one resident (Resident #2) after the facility placed the resident (Resident #1) on one-on-one with a staff The facility census was 54. Review of the facility's policy titled Abuse, Neglect and Exploitation, revised 10/2022, showed the following:-The resident has the right to be free from verbal, sexual, physical and mental abuse and involuntary seclusion. It is the policy of Medicalodges, Inc., to treat each resident with respect, kindness, dignity and care, to keep them free from abuse and neglect and to take swift and immediate action to investigate and adjudicate alleged resident abuse and neglect;-Abuse is the willful infliction of injury; [...]

Inspectors wroteBased on interview and record review, the facility failed to implement a complete abuse and neglect program that completed all screenings when staff failed to complete a Nurse Aide (NA) Registry (a registry which shows if someone has a Federal Indicator (indicates individuals who had a previous incident involving abuse, neglect, or misappropriation of property that would prevent the employee from working in a certified long-term care facility) for one (Registered Nurse (RN) H) of four sampled employees . The facility census was 55. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain a complete infection control program when staff failed to use Enhanced Barrier Precautions (EBP - an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs - microorganism that has developed resistance to one or more classes of antibiotics, making infections caused by it more difficult to treat) in nursing homes) during wound care for two residents (Residents #29 and #48). The facility census was 55. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure they maintained a medication administer error rate of less than 5% when staff failed to administer the correct medication to one resident (Resident #4) and failed to administer a medication to one resident (Residents #18), resulting in 2 errors out of 28 opportunities (a medication error rate of 7.1%). The facility census was 55. Review of the facility policy Medication Error Reporting and Adverse Drug Reaction Prevention, dated 01/23, showed the following:-The facility utilizes a system to assure that medication usage is evaluated on an ongoing basis;-Medication error shall be defined as any preventable event that may cause or lead to inappropriate medication use. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement comprehensive person-centered care plans for four residents (Residents #5, Resident #12, Resident #26 and Resident #47) that addressed side rails usage. The facility census was 50. Review of the facility's policy titled, Electronic Care Plan, dated 12/2018, showed the following: -The facility is to develop a plan of care to attain and maintain the highest practical level of physical, psychological, emotional and social well-being for each resident in the facility. Review of the facility's policy titled, Side Rail Use and Assessment, undated, showed the following: [...]

Inspectors wroteBased on interview, and record review, the facility failed to promote self-determination of all residents when staff failed to work with one resident (Resident #27) who requested a room change due to conflict with a roommate. A sample of 16 residents was reviewed in a facility with a census of 50. Review of the facility form titled, Resident Rights, undated, showed the following: -The facility shall ensure that each resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. The facility shall protect and promote the rights of each resident as set forth in the following standards; -The sharing of personal space will only be by agreement of each resident. [...]

Inspectors wroteBased on interview and record review, the facility failed to immediately notify the physician and responsible party of a fall with injury for one resident (Resident #41) out of 16 sampled residents in a facility with a census of 50. Review of the facility policy titled, Falls Management, revised December 2022, showed the following: -After a fall occurs the licensed nurse is to initiate the risk management event reporting process. The process is to include a physical assessment; -Physician and responsible party are to be notified following a fall; -Physician and responsible party are to be notified following a fall occurrence with documentation of notification present in the clinical record. 1. Review of Resident #41's face sheet showed: -admission date of 12/30/22; -readmission date of 03/15/24; -A legal guardian listed as the responsible party/emergency contact #1; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a clean and homelike environment for all residents when when staff failed to clean/maintain the toilet riser in one resident's (Resident #29) bathroom. The facility census was 50. Review of the facility's policy titled, Housekeeping, Laundry and Maintenance, undated, showed staff to clean all resident bathrooms daily and provide emergency cleaning as need arises. 1. Review of Resident #29's face sheet (admission data), dated 04/18/24, showed an admission date of 12/14/19. Review of the resident's Care Plan, dated 03/31/24, showed the following: -Cognitive skills intact; -Independent with decision making; -Required staff assistance with activities of daily living (ADL) due to limitations. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify and coordinate with the State-designated authority following newly evident or serious mental illness for one resident (Resident #51) who had a negative Level I Preadmission Screening and Resident Review (PASARR - Level I is administered to determine if a PASARR Level II (an in-depth evaluation and determination of an individual by a Medicaid-certified nursing facility, evaluation is needed prior to admission for possible serious mental disorders, intellectual disabilities and related conditions to ensure that residents identified receive care and services in the most integrated setting appropriate to their needs)). The facility census was 50. Review showed the facility did not provide a policy regarding PASARR requirements. Review of the Missouri Department of Health and Senior Services web-site showed the following: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to timely notify the physician, responsible party, and registered nurse on-call of a fall for one resident (Resident #41) who complained of pain and decreased mobility to his/her left hip/leg, potentially contributing to a delay in the treatment of this resident's fractured femur, out of 16 sampled residents in a facility with a census of 50. Review of the facility policy titled, Falls Management, revised December 2022, showed the following: -The facility strives to minimize the risk for resident falls and to reduce injuries associated with resident falls; -After a fall occurs the licensed nurse is to initiate the risk management event reporting process. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to perform wound care following professional standard of practice and in manner to prevent possible contamination of the wound when staff failed to following infection control practices, including appropriate handwashing, during the wound care treatment for two residents (Resident #1 and Resident #2). The facility census was 54. Review of the facility policy, Handwashing, undated, showed the following: -Hands must be washed in such a manner as to decrease the transmission of pathogenic organisms. Hands should be washed carefully for at least 15 seconds; -After caring for one resident and before caring for the next resident; -Before and after any resident care; -Before and after all procedures such as doing dressings and treatments; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to document identification and use of possible alternatives prior to use of side rails; failed to document side rail assessments of risk versus benefits; failed to obtain written informed consents for the use of side rails prior to installation; and failed to complete ongoing assessments of appropriateness of side rails use for six residents (Resident #8, #33, #35, #40, #97, and #98). The facility's census was 49. Record review of the facility's undated policy, Side Rail Use and Assessment, showed the following: -The facility will use the Clinical Guidance for the Assessment and Implementation of Bed Rails in Hospitals and Long Term Care Facilities and Home Care Settings, dated 2003, developed by the hospital bed safety workgroups as the primary protocol for the use of side rails. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a medication error rate of less then 5% when staff made three errors out of 33 opportunities, resulting in an error rate of 9.09%, when staff failed to correctly flush between medications administered via PEG-tube (percutaneous endoscopic tube: inserted through the wall of the abdomen directly into the stomach, used to give drugs, liquids, liquid food) for one resident (Resident #1). The facility had a census of 49. According to an article written by [NAME], RPh (Registered Pharmacist), FASCP (Fellowship; American Society of Consultant Pharmacists); Pharmacy & Therapeutics: A Peer-Reviewed Journal for Managed Care and Hospital Formulary Management, October 2013; all medications given through a feeding tube should be set up and administered separately, flushing before, in between, and after all medications. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure residents were free of significant medication errors when staff failed to correctly flush between medications administered via PEG-tube (percutaneous endoscopic tube - inserted through the wall of the abdomen directly into the stomach, used to give drugs, liquids, liquid food) for one resident (Resident #1). The facility had a census of 49. According to an article written by [NAME], RPh (Registered Pharmacist), FASCP (Fellowship; American Society of Consultant Pharmacists); Pharmacy & Therapeutics: A Peer-Reviewed Journal for Managed Care and Hospital Formulary Management, October 2013; all medications given through a feeding tube should be set up and administered separately, flushing before, in between, and after all medications. [...]