Medicalodges Paola

Inspectors wroteBased on observation and interview, the facility failed to store and prepare food in the kitchen under sanitary conditions to prevent foodborne illnesses.

Inspectors wroteBased on record review, observations, and interviews, the facility failed to implement adequate infection control practices when staff failed to store Resident (R)2's nebulizer (a device that changes liquid medication into a mist easily inhaled into the lungs) and nasal oxygen mask in a sanitary manner when not in use. The facility failed to store R27's continuous positive airway pressure (CPAP- ventilation device that blows a gentle stream of air into the nose to keep the airway open during sleep) in a sanitary container when not in use. The facility failed to ensure the dryer vents were cleaned, and clean laundry was transported in a covered cart to prevent contamination. The facility failed to ensure staff were provided with Personal Protective Equipment (PPE) for sorting soiled laundry. [...]

Inspectors wroteBased on observation, interviews, and record review, the facility failed to maintain a clean, homelike environment.

Inspectors wroteBased on interviews and record review, the facility failed to inform Resident (R) 27 and/or their representatives regarding the risks related to psychotropic (alters mood or thoughts) medications to promote informed consent to the medication.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure resident trust accounts were accessible within the same day as required to accommodate Resident (R) 5's request for thirty dollars on a weekend.

Inspectors wroteBased on observation, interview, and record review, the facility failed to identify and implement resident-centered fall interventions for Resident (R) 2. Additionally, the facility failed to provide foot pedals when staff propelled R2 in his wheelchair.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure Resident (R) 64's continuous positive airway pressure (CPAP- ventilation device that blows a gentle stream of air into the nose to keep airway open during sleep) mask, oxygen tubing, and nebulizer (a device that changes liquid medication into a mist easily inhaled into the lungs) was stored in a sanitary manner to decrease exposure and contamination for R64 who has a history of pneumonia (an infection in the lungs).

Inspectors wroteBased on record reviews and interviews, the facility failed to administer the Pneumococcal Conjugate Vaccine (PCV20- vaccination for bacterial pneumonia infections) for Resident (R)27 after obtaining consent for the vaccine. Findings Included:- Review of R27's clinical record revealed R27 received the Pneumovax 23 on 11/03/2020 and had consented for PCV20 on 11/18/2025. R27's clinical record lacked documentation the PCV20 was administered to R27. On 07/14/2026 at 09:43 AM, Administrative Nurse E stated immunization consents or declinations were obtained from the resident or the guardian on admission. She stated the medical records nurse tracked all immunizations when she was with the facility. Administrative Nurse E stated if a resident consented for a vaccine, the vaccine was ordered and given. She stated she was the nurse following up on immunizations. [...]

Inspectors wroteBased on record reviews and interviews, the facility failed to administer the Pneumococcal Conjugate Vaccine (PCV20- vaccination for bacterial pneumonia infections) for Resident (R)27 after obtaining consent for the vaccine.

Inspectors wroteBased on interview and record review the facility failed to submit complete and accurate staffing information to the federal regulatory agency through Payroll Based Journaling (PBJ).

Inspectors wroteThe facility reported a census of 63 residents and one kitchen. Based on observation, record review, and interview, the facility failed to prepare and serve food under sanitary conditions, to the residents of the facility appropriately to prevent the potential for food borne bacteria placing them at risk of food-related illness.

Inspectors wroteThe facility reported a census of 63 residents. Based on interview, and record review, the facility failed to ensure the mandatory 12-hours of education were completed for one Certified Nurse Aide (CNA) as required. This placed the residents at risk for decreased quality of care.

Inspectors wroteThe facility reported a census of 63 residents. Based on observation, interview and record review, the facility failed to maintain a clean, comfortable, and homelike environment in four of 23 resident rooms on the south hall placing the residents at risk of an uncomfortable and unhomelike environment.

Inspectors wroteThe facility identified a census of 63 residents. The sample included 17 residents including five residents reviewed for unnecessary medications. Based on record review, interview and observation, the facility failed to act upon blood pressure monitoring for Resident (R) 50 and administer a hypertensive (high blood pressure) medication per the physician orders. This placed the resident at risk for complications related to high blood pressure and ineffective medication regimen.

Inspectors wroteThe facility reported a census of 63 residents. The sample included 17 residents. Based on interviews, record reviews and observation, the facility staff failed to implement 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 Resident (R)8 and for R21 who had wounds and received wound care. This deficient practice placed the residents at increased risk for infections.

Inspectors wroteThe facility reported a census of 63 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 the daily licensed and unlicensed staff hours, and daily census as required.

Inspectors wroteThe facility reported a census of 65 residents. The sample included three residents reviewed for accidents. Based on observation, interview, and record review, the facility failed to prevent the neglect of Resident (R)1, when staff did not utilize appropriate transfer equipment to safely meet the needs of R1, who displayed signs of weakness during cares. On 08/28/24 at 02:40 PM, Licensed Nurse (LN) G, Certified Nurse Aide (CNA) M, CNA N, and Certified Medication Aide (CMA) R assisted R1 to stand, with use of a gait belt that was not the appropriate size for R1. As two of the staff members attempted to pull R1's incontinence brief up, R1's legs became weak, and staff lowered R1 to the floor. During the lowering, the resident's left leg buckled underneath the resident and rotated outward, which caused a popping noise. [...]

Inspectors wroteThe facility reported a census of 65 residents. The sample included three residents reviewed for accidents. Based on observation, interview, and record review, the facility failed to report the 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) of Resident (R)2 to the State Agency, as required. On 08/27/24 at 08:48 PM R2 left the facility without staff knowledge or supervision and at approximately 10:41 PM, Law Enforcement called the facility to advise them they had received calls noting that R2 was walking on the highway, entered a gas station approximately 0.9 miles from the facility. [...]

Inspectors wroteThe facility reported a census of 65 residents. The sample included three residents reviewed for accidents. Based on observation, interview, and record review, the facility failed to protect Resident (R) 2 from possible harm when he exited the facility unsupervised and without staff knowledge (elopement) on 08/27/24 at 08:48 PM. At approximately 10:41 PM, Law Enforcement called the facility to inform them they received calls noting R2 was walking on the highway, then entered a gas station (approximately 0.9 miles from the facility), threatened a store clerk, and wanted to buy cigarettes with postage stamps. Law Enforcement informed License Nurse (LN) H someone needed to come to their location because Law Enforcement had R2 surrounded with their patrol cars due to his threats of yelling, cursing and agitation to Law Enforcement Officers and the store clerk. [...]

Inspectors wroteThe facility reported a census of 62 residents with 18 residents selected for review, which included two residents reviewed for elopement. Based on observation, interview, and record review the facility failed to ensure staff provided a safe and secure environment to include adequate supervision for cognitively impaired Resident (R) 44, who the facility care planned for 15-minute checks due to a history of making elopement statements. On 10/22/23 at 05:07 AM R44 left the facility and walked approximately 0.6 miles to a local grocery store (which opened at 06:00 AM). The resident was observed in the grocery store eating at the salad bar. The facility did not realize R44 was missing for four hours and 23 minutes, when local police called the facility at 09:15 AM to report they located the resident and then returned the resident to the facility. [...]

Inspectors wroteThe facility reported a census of 62 residents. Based on observation, record review and interview, the facility failed to prepare and serve food under sanitary conditions, to the residents of the facility appropriately to prevent the potential for the spread of food borne bacteria.

Inspectors wroteThe facility reported a census of 62 residents. Based on observation and interview, the facility failed to ensure a safe, sanitary, and homelike environment for the residents of the facility in the identified resident areas.

Inspectors wroteThe resident reported a census of 62 residents. Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents and staff in the facility kitchen areas.

Inspectors wroteThe facility reported a census of 62 residents with 18 residents sampled, including one resident reviewed for dignity. Based on observation, interview and record review, the facility failed to show respect and dignity to one Resident (R)25, by not having a dignity bag for his indwelling urinary catheter (a thin, hollow tube inserted through the urethra into the urinary bladder to collect and drain urine) collection bag.

Inspectors wroteThe facility reported a census of 62 residents with 18 residents sampled. Based on observation, interview and record review, the facility failed to review and revise the care plan for one Resident (R)25, with the failure to include staff instructions on the use of a dignity bag in the care plan for the resident's indwelling urinary catheter collection bag.

Inspectors wroteThe facility reported a census of 62 residents with 18 residents sampled. Based on observation, interview and record review, the facility failed to draw the physician ordered labs for this one dependent resident, Resident (R)57, to monitor his well-being and physical/mental health.

Inspectors wroteThe facility reported a census of 62 residents. Based on observation and interview, the facility failed to ensure containment of biohazardous waste in a manner to prevent the spread of infection for one Resident (R)47 and failed to obtain identification of the causative organism for the resident's chronic wound.

Inspectors wroteThe facility reported a census of 62 residents with three selected for review for elopement. Based on observation, interview, and record review the facility failed to prevent an elopement when Resident (R)1 exited the facility grounds, unsupervised on 07/30/23 at 04:48 PM and remained outside of the facility grounds for approximately four hours. While out of the facility unsupervised, the resident walked 0.5 miles to a convenience store on a two-lane paved road. The temperature was 96 degrees Fahrenheit. While at the convenience store, the resident complained of chest pain and Emergency Medical Service (EMS) was called, and the resident was transported to the emergency room. Certified Medication Aide (CMA) R did not locate the resident at dinner time around 05:00 PM and notified Licensed Nurse (LN) H, who told CMA R to look for the resident. [...]