Inspection Reports for Medicalodges Leavenworth
1503 OHIO ST, KS, 66048-2932
Back to Facility ProfileInspection Report Summary
The most recent inspection on July 29, 2025, identified a deficiency related to failure to protect a cognitively impaired resident from financial misappropriation, which caused emotional distress and immediate jeopardy. Earlier inspections showed a pattern of deficiencies involving resident care, infection control, medication management, staffing, and documentation, with multiple complaint investigations substantiating issues such as abuse reporting delays and nursing competency concerns. The main themes across citations included resident protection and safety, nursing staff training and oversight, infection prevention, and medication administration practices. Several complaint investigations were substantiated, including the recent financial misappropriation case, while others involved unsubstantiated allegations or issues that were later corrected. The facility has demonstrated some improvement following prior citations, but recent findings indicate ongoing challenges in safeguarding residents and ensuring consistent staff competency.
Deficiencies (last 13 years)
Deficiencies (over 13 years)
23.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
297% worse than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
28
21
14
7
0
Census
Latest occupancy rate
37 residents
Based on a July 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Plan of Correction
Deficiencies: 1
Jul 29, 2025
Visit Reason
The facility was notified of failure to protect a cognitively impaired resident from misappropriation of funds and financial loss, which caused emotional distress and placed the resident in immediate jeopardy.
Findings
The facility identified a financial misappropriation incident involving a cognitively impaired resident resulting in approximately $6000 loss. Immediate corrective actions were implemented including suspension and termination of involved staff, account audits, resident counseling, security changes, staff training, law enforcement notification, and resident communication.
Severity Breakdown
J: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to protect a cognitively impaired resident from misappropriation of funds and financial loss causing emotional distress and immediate jeopardy. | J |
Report Facts
Financial loss amount: 6000
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Staff C | Suspended and terminated due to involvement in misappropriation of funds | |
| Administrative Staff A | Provided the IJ template and notified of the facility's failure |
Inspection Report
Complaint Investigation
Census: 37
Deficiencies: 1
Jul 29, 2025
Visit Reason
The inspection was conducted as a result of multiple complaint investigations regarding misappropriation of resident property at Medicalodges Leavenworth.
Findings
The facility failed to protect a cognitively impaired resident (R1) from misappropriation of funds by an administrative staff member who used the resident's credit card for personal purchases, causing emotional distress and a financial loss of approximately $6000. Immediate corrective actions were taken including suspension and termination of the staff member, resident counseling, and policy reinforcement.
Complaint Details
The visit was complaint-related involving multiple complaint investigations (2571386, 2571397, 2569936, 2566521, 2567530, and 1502319). The misappropriation was substantiated, involving Administrative Staff C who admitted to unauthorized use of resident R1's credit card, resulting in a financial loss and emotional distress to the resident.
Severity Breakdown
J: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to protect a cognitively impaired resident from misappropriation of funds by a staff member who used the resident's credit card for personal purchases. | J |
Report Facts
Resident census: 37
Financial loss: 6000
Suspicious charges: 5987.14
Partial reimbursement: 2500
Number of suspicious charges: 50
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Staff C | Administrative Staff | Staff member who misappropriated resident funds and was suspended and terminated |
| Administrative Staff A | Administrative Staff | Staff member who discovered the misappropriation, suspended Administrative Staff C, and notified law enforcement |
| Social Services X | Social Services | Staff member who discovered suspicious charges and reported to Administrative Staff A |
| Administrative Nurse D | Administrative Nurse | Staff member interviewed regarding facility policy on resident financial information |
Inspection Report
Re-Inspection
Deficiencies: 0
Nov 15, 2024
Visit Reason
An offsite revisit survey was conducted on 11/15/24 for all previous deficiencies cited on 09/25/24 to verify correction of cited deficiencies.
Findings
All deficiencies cited in the previous inspection have been corrected as of the compliance date of 10/31/24, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: Deficiencies cited on 09/25/24 and corrected by 10/31/24
Inspection Report
Plan of Correction
Deficiencies: 13
Sep 25, 2024
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during the inspection conducted on 2024-09-25.
Findings
The Plan of Correction outlines corrective actions for multiple deficiencies related to resident care, nursing staff education, infection control, medication management, and staff training, with compliance dates set for 10-31-2024.
Severity Breakdown
D: 6
F: 5
E: 2
Deficiencies (13)
| Description | Severity |
|---|---|
| Heels floated per care plan | D |
| Anchor to secure catheter with care plan revised | D |
| Respiratory tubing and equipment maintained in appropriate bags with dates | D |
| Staff education regarding RN coverage | F |
| Staff performance reviews and required 12 hour in-service training | F |
| Shift to shift narcotic count sheets completed at shift change | E |
| Pharmacy recommendations reviewed and follow up completed | D |
| Gradual reduction or supporting documentation for psychotropic medications | D |
| Certified food service manager requirement | F |
| Care plans revised to reflect current care and services collaboration with hospice | D |
| Enhanced Barrier Precautions with required signage and hand hygiene | E |
| Facility has an Infection Preventionist | F |
| Certified nursing aides educated on 12 hours per year training requirements | F |
Report Facts
Compliance date: Oct 31, 2024
Inspection date: Sep 25, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Shawnahoschouer | Administrator | Submitted the Plan of Correction |
Inspection Report
Complaint Investigation
Census: 34
Deficiencies: 13
Sep 25, 2024
Visit Reason
The inspection was a health resurvey and complaint investigation related to multiple areas of resident care and facility compliance.
Findings
The facility was found deficient in multiple areas including pressure ulcer prevention, catheter care, respiratory equipment sanitation, RN coverage, nurse aide performance reviews and training, pharmacy services including medication regimen review and psychotropic drug use, dietary staffing, hospice care collaboration, infection prevention and control, and infection preventionist qualifications.
Complaint Details
The inspection included a complaint investigation identified as KS00189923.
Severity Breakdown
SS=D: 6
SS=E: 2
SS=F: 4
Deficiencies (13)
| Description | Severity |
|---|---|
| Failed to implement pressure-reducing interventions for Resident 16, placing them at risk for pressure ulcer development and worsening. | SS=D |
| Failed to ensure Resident 26 had an anchor for his suprapubic catheter to prevent pulling and injury. | SS=D |
| Failed to ensure Resident 27's CPAP mask and nasal cannula were stored in a sanitary manner, increasing risk of respiratory infection. | SS=D |
| Failed to provide Registered Nurse coverage eight consecutive hours a day, seven days a week. | SS=F |
| Failed to ensure three Certified Nurse Aides had required yearly performance evaluations completed. | SS=F |
| Failed to ensure controlled substances were accurately accounted for and reconciled between shifts. | SS=E |
| Failed to ensure medication regimen review was addressed by physicians and Consultant Pharmacist recommendations for gradual dose reduction were followed for Residents 3, 9, and 26. | SS=D |
| Failed to ensure Residents 3 and 9 had gradual dose reductions or physician documentation for psychotropic medications, and Resident 9 lacked CMS-approved indication for antipsychotic use. | SS=D |
| Failed to employ a full-time certified dietary manager to oversee nutritional services for 34 residents. | SS=F |
| Failed to ensure collaboration and communication between nursing home and hospice provider for Resident 8, including documentation of hospice services, medications, and equipment. | SS=D |
| Failed to implement signage or indicators for Enhanced Barrier Precautions, sanitize shared equipment, ensure hand hygiene, and store respiratory equipment in a sanitary manner. | SS=E |
| Failed to designate a qualified Infection Preventionist employed at least part-time responsible for the facility's Infection Prevention and Control Program. | SS=F |
| Failed to ensure one of three Certified Nurse Aides reviewed had the required 12 hours of in-service education. | SS=F |
Report Facts
Census: 34
Deficiencies cited: 13
RN coverage missing dates: 5
CNA staff without yearly performance evaluations: 3
Residents on Enhanced Barrier Precautions: 7
Residents on Transmission-Based Precautions: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Staff C | Acting Infection Preventionist | Named as acting Infection Preventionist without required qualifications. |
| Administrative Nurse D | Administrative Nurse | Provided statements regarding expectations for infection control, RN coverage, and medication regimen review. |
| Licensed Nurse G | Licensed Nurse | Provided statements regarding catheter care, respiratory equipment storage, and medication regimen review. |
| Certified Nurse Aide M | Certified Nurse Aide | Observed performing catheter care and provided statements about care plans. |
| Certified Nurse Aide P | Certified Nurse Aide | Observed performing catheter care. |
| Dietary Staff BB | Dietary Staff | Stated not yet certified as dietary manager. |
Inspection Report
Re-Inspection
Deficiencies: 0
Oct 27, 2023
Visit Reason
An offsite revisit survey was conducted on 10/27/23 for all previous deficiencies cited on 09/18/23.
Findings
All deficiencies have been corrected as of the compliance date of 10/20/23, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Re-Inspection
Deficiencies: 0
Oct 6, 2023
Visit Reason
An offsite revisit survey was conducted on 10/06/23 for all previous deficiencies cited on 08/28/23.
Findings
All deficiencies have been corrected as of the compliance date of 09/20/23, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Complaint Investigation
Census: 35
Deficiencies: 2
Sep 18, 2023
Visit Reason
The inspection was conducted as a complaint investigation (#KS00182670) regarding failure to report and investigate an allegation of abuse involving bruising of unknown origin on Resident 1 (R1).
Findings
The facility failed to report an allegation of abuse involving bruising of unknown origin on R1 to the State Agency within the required timeframe and failed to conduct a thorough investigation of the bruising. This placed R1 at risk for ongoing abuse and/or neglect.
Complaint Details
The complaint investigation #KS00182670 focused on allegations of abuse related to bruising of unknown origin on Resident 1. The facility failed to report the allegation timely and did not conduct an adequate investigation, placing the resident at risk.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to report an allegation of abuse involving bruising of unknown origin to the State Agency within the required timeframe. | SS=D |
| Failure to investigate bruising of unknown origin for Resident 1, placing the resident at risk for unidentified and ongoing abuse and/or neglect. | SS=D |
Report Facts
Census: 35
Sample size: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse G | Licensed Nurse | Noted bruising on Resident 1's forearms at discharge and provided information about the bruising. |
| Administrative Nurse D | Administrative Nurse | Responsible for investigation; admitted failure to report and investigate bruising of unknown origin on Resident 1. |
| Administrative Staff A | Administrative Staff | Involved in investigation process and acknowledged bruising should have been reported and investigated. |
Inspection Report
Plan of Correction
Deficiencies: 2
Sep 18, 2023
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 outlines corrective actions including education of management staff and nurses on reporting abuse, neglect, and exploitation, and training of the Director of Nursing and Administrator on conducting investigations related to these issues. The clinical management team will monitor compliance through documentation review and risk meetings.
Severity Breakdown
D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to timely report abuse, neglect, exploitation, and injuries of unknown origin per state protocol. | D |
| Failure to properly conduct investigations regarding abuse, neglect, exploitation, and injuries of unknown origin. | D |
Inspection Report
Complaint Investigation
Census: 31
Deficiencies: 2
Aug 28, 2023
Visit Reason
The inspection was conducted as a complaint investigation based on allegations related to nursing staff competency and medication management, specifically concerning the handling of fentanyl patches for residents.
Findings
The facility failed to ensure licensed nursing staff possessed the necessary skills to competently manage fentanyl patches, including failure to remove previous patches before applying new ones and improper verification of patch removal and destruction. This placed residents at risk for incompetent nursing care, unnecessary side effects, and potential diversion of controlled substances.
Complaint Details
The investigation involved complaint investigations #KS00182346 and KS00182353 focusing on fentanyl patch management and nursing competency.
Severity Breakdown
SS=D: 1
SS=E: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure licensed nurses possessed skills necessary to provide competent nursing services related to fentanyl patch management, including failure to remove previous patches before applying new ones. | SS=D |
| Failure to follow standards of practice regarding reconciliation of controlled narcotic substances, including signing narcotic control logs without visual verification and wasting fentanyl patches without witnesses. | SS=E |
Report Facts
Census: 31
Residents reviewed for fentanyl patch use: 4
Dates of fentanyl patch applications and removals: Multiple specific dates between 08/12/23 and 08/28/23 documented in narcotic count sheets and nurse notes
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LN G | Licensed Nurse | Named in medication error finding related to fentanyl patch application and documentation |
| LN H | Licensed Nurse | Named in medication error finding related to fentanyl patch removal verification and narcotic log signing |
| LN I | Licensed Nurse | Assessed resident and removed older fentanyl patch after notification |
| LN J | Licensed Nurse | Involved in wasting fentanyl patch and narcotic count sheet signing |
| LN K | Licensed Nurse | Witnessed fentanyl patch wasting and questioned practice |
| Administrative Nurse D | Administrative Nurse | Provided education to staff and stated expectations for narcotic waste verification |
| Certified Medication Aide R | Certified Medication Aide | Noted presence of multiple fentanyl patches on resident and alerted nursing staff |
Inspection Report
Plan of Correction
Deficiencies: 2
Aug 28, 2023
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies cited in a prior inspection report dated 08/28/2023.
Findings
The plan addresses deficiencies related to the administration and removal of Fentanyl patches by requiring two licensed nurses to perform these tasks, auditing compliance for all residents with Fentanyl orders, and educating nursing staff on proper procedures. The Director of Nursing or designee will monitor compliance and report audit results to the quality assurance committee.
Severity Breakdown
D: 1
E: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Resident #1 Fentanyl patch is to be removed by 2 licensed nurses, and the new patch to be applied by 2 licensed nurses. | D |
| All residents on narcotics were audited for compliance of reconciliation of controlled narcotic substances; education provided on standards of practice in reconciliation, signing, destruction, and verification of removal of Fentanyl patches. | E |
Inspection Report
Re-Inspection
Deficiencies: 0
Jun 20, 2023
Visit Reason
A revisit survey was conducted on 06/20/23 for all previous deficiencies cited on 05/31/23 to verify correction of deficiencies.
Findings
All deficiencies cited on 05/31/23 have been corrected as of 06/15/23, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Re-Inspection
Census: 35
Deficiencies: 6
May 31, 2023
Visit Reason
This was a non-compliance revisit inspection to verify correction of previously cited deficiencies related to quality of care, pressure ulcer treatment, mobility, psychotropic medication use, infection control, and immunizations.
Findings
The facility failed to obtain physician-ordered daily weights and notify the physician for Resident 15, failed to prevent cross-contamination during wound care for Resident 25, failed to ensure restorative care was performed for Resident 25, failed to provide documented rationale for psychotropic medication use for Resident 15, failed to prevent cross-contamination during wound care, and failed to ensure pneumococcal vaccinations were administered to Residents 10, 15, and 16 after consent was obtained.
Severity Breakdown
SS=D: 6
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to obtain physician ordered daily weights and notify physician regarding weight gain for Resident 15 on diuretic medications. | SS=D |
| Failed to prevent cross-contamination during wound care for Resident 25. | SS=D |
| Failed to ensure restorative care was performed for Resident 25. | SS=D |
| Failed to provide documented physician rationale for continued use of psychotropic medication Seroquel for Resident 15. | SS=D |
| Failed to prevent cross-contamination during wound care for Resident 25 (infection control). | SS=D |
| Failed to ensure Residents 10, 15, and 16 received pneumococcal vaccination after obtaining consent. | SS=D |
Report Facts
Census: 35
Sample size: 13
Weight gain: 6
Medication dosage: 50
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Named in findings related to wound care, weight notification, immunization consent, and psychotropic medication rationale |
| Licensed Nurse G | Licensed Nurse | Named in findings related to wound care and hand hygiene |
| Certified Nurse Aide M | Certified Nurse Aide | Named in findings related to weight obtaining and hand hygiene |
| Certified Nurse Aide N | Certified Nurse Aide | Named in findings related to restorative care |
Inspection Report
Plan of Correction
Deficiencies: 6
May 31, 2023
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 monitoring resident weights, infection control during wound care, restorative nursing documentation, psychotropic medication management, infection control education, and pneumococcal vaccination administration.
Severity Breakdown
D: 6
Deficiencies (6)
| Description | Severity |
|---|---|
| Nursing staff to collect and monitor the weights of residents as ordered per MD. | D |
| All treatments performed by staff to follow infection control practices during wound care to prevent risk of wound worsening and complications related to infection. | D |
| Documentation to be completed in the EMR by restorative aide and monthly by designated restorative nurse. | D |
| Resident #15 physician completed gradual dose reduction and seroquel was discontinued. | D |
| All staff to be educated regarding infection control guidelines while completing tasks. | D |
| Facility nurses to provide pneumococcal vaccines after resident consent and update immunization records. | D |
Report Facts
Deficiencies cited: 6
Date of physician discontinuation of seroquel: Jun 12, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact for Plan of Correction assistance | |
| Haley Tinch | Administrator | Submitted the Plan of Correction |
| Felicia Majewski | Added and modified the Plan of Correction |
Inspection Report
Complaint Investigation
Census: 39
Deficiencies: 22
Apr 10, 2023
Visit Reason
The inspection was a Health Resurvey and Complaint Investigation to evaluate compliance with resident rights, reasonable accommodations, communication, privacy, safety, care planning, medication administration, infection control, and other regulatory requirements.
Findings
The facility was found deficient in multiple areas including failure to ensure resident privacy during care, failure to provide reasonable accommodations, failure to maintain confidentiality of protected health information, failure to maintain a safe and homelike environment, failure to provide timely transfer/discharge notices, incomplete baseline and comprehensive care plans, failure to provide activities on weekends, failure to follow physician orders for daily weights and medication administration, inadequate infection control practices, failure to provide hospice care plans, lack of RN coverage for 8 consecutive hours 7 days a week, failure to provide dementia care, failure to monitor IV therapy properly, failure to provide pneumococcal immunizations, and failure to ensure psychotropic medications were used appropriately.
Complaint Details
The visit was triggered by complaints related to resident rights violations, inadequate care planning, medication errors, infection control breaches, and lack of proper staffing.
Severity Breakdown
SS=F: 5
SS=E: 2
SS=D: 13
Deficiencies (22)
| Description | Severity |
|---|---|
| Resident rights and dignity were not respected when privacy was not provided during care. | SS=D |
| Failure to provide reasonable accommodations including call light within reach and wheelchair foot pedals during transport. | SS=D |
| Failure to ensure privacy of protected health information; COVID-19 test swabs and resident census left unsecured and visible. | SS=F |
| Failure to maintain a safe, homelike environment including unrepaired room damages. | SS=D |
| Failure to provide timely written notice of transfer/hospitalization to resident and family. | SS=D |
| Failure to develop and revise baseline and comprehensive care plans addressing oxygen therapy, IV antibiotic care, and dialysis care. | SS=D |
| Failure to provide discharge summary documenting resident's stay and care. | SS=D |
| Failure to provide activities during weekends. | SS=E |
| Failure to follow physician ordered daily weights for resident on diuretics. | SS=D |
| Failure to implement infection control practices during wound care and improper storage of COVID-19 PPE and test swabs. | SS=F |
| Failure to provide appropriate treatment and services to prevent reduction in range of motion and mobility for residents with contractures. | SS=D |
| Failure to ensure resident environment free of accident hazards including unsecured hazardous materials and medical waste accessible to residents. | SS=E |
| Failure to ensure physician orders and care for oxygen therapy including proper storage of tubing and nasal cannula. | SS=D |
| Failure to monitor central venous catheter for signs of infection, bleeding, and proper dressing in place for resident receiving dialysis. | SS=D |
| Failure to ensure RN coverage for at least eight consecutive hours, seven days a week. | SS=F |
| Failure to provide appropriate dementia care and activities for resident with wandering behaviors. | SS=D |
| Failure to identify and report insulin medication given outside physician ordered parameters. | SS=D |
| Failure to provide adequate indication and physician rationale for continued use of antipsychotic medication Seroquel. | SS=D |
| Failure to ensure hospice plan of care was in place and available for facility staff direction. | SS=D |
| Failure to ensure infection prevention and control including proper storage of COVID-19 test swabs, PPE, and prevention of cross contamination during wound care. | SS=F |
| Failure to provide pneumococcal immunizations to residents who consented to receive them. | SS=D |
| Failure to ensure influenza immunizations were offered and documented appropriately. | SS=D |
Report Facts
Residents on isolation: 5
Days without RN coverage: 48
Residents reviewed: 13
Residents positive for COVID-19: 5
Blood sugar levels outside ordered parameters: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Provided multiple statements on care plans, infection control, RN coverage, and hospice care. |
| Licensed Nurse G | Licensed Nurse | Provided statements on privacy, care plans, medication administration, and infection control. |
| Certified Nurse Aide M | Certified Nurse Aide | Provided statements on resident care, privacy, activities, and infection control. |
| Administrative Staff A | Administrative Staff | Provided statements on infection control and activities. |
| Activities Coordinator X | Activities Coordinator | Provided statements on resident activities and dementia care. |
| Licensed Nurse H | Licensed Nurse | Observed wound care and infection control practices. |
| Certified Nurse Aide N | Certified Nurse Aide | Provided statements on restorative care and resident care. |
Inspection Report
Plan of Correction
Deficiencies: 25
Apr 10, 2023
Visit Reason
This document is a Plan of Correction submitted by Medicalodges Leavenworth1 following deficiencies cited in a prior inspection conducted on April 10, 2023.
Findings
The plan outlines corrective actions addressing multiple deficiencies related to resident rights, privacy, call light accessibility, mail delivery, discharge notices, record confidentiality, environmental safety, care plan updates, infection control, wound care, restorative services, fall prevention, medication administration, hospice care coordination, immunizations, and RN coverage.
Severity Breakdown
D: 18
F: 4
E: 2
C: 1
Deficiencies (25)
| Description | Severity |
|---|---|
| Resident #140 no longer resides at the facility; education on resident rights, privacy, dignity, and respect. | D |
| Call light accessibility and foot pedals for residents requiring assistance. | D |
| Providing residents mail on weekends. | C |
| Resident 240 no longer resides; timely notice of service changes. | D |
| Resident records privacy and confidentiality. | F |
| Environmental safety issues fixed (paneling and outlet cover). | D |
| Notice to resident prior to or during hospitalization. | D |
| Updating care plans appropriately and timely. | D |
| Dialysis care plan revisions and monitoring. | D |
| Weekend activities for residents. | E |
| Weight monitoring for residents under isolation. | D |
| Infection control practices during wound care. | D |
| Restorative services and documentation. | D |
| Bed position for residents at risk of falls. | E |
| Bowel and bladder program assessments and care plans. | D |
| IV antibiotic and fluid orders and infection control. | D |
| Oxygen therapy orders and infection control. | D |
| Dialysis catheter monitoring and care plan updates. | D |
| RN coverage for 8 consecutive hours. | F |
| Dementia care education and training. | D |
| Medication administration outside physician orders. | D |
| Psychotropic medication use and documentation. | D |
| Hospice care coordination plan. | D |
| Infection control in wound care and PPE handling. | F |
| Pneumococcal vaccine administration and documentation. | D |
Inspection Report
Re-Inspection
Deficiencies: 0
Mar 11, 2022
Visit Reason
An offsite revisit survey was conducted on 03/11/22 for all previous deficiencies cited on 01/04/22 to verify correction of prior deficiencies.
Findings
All deficiencies have been corrected as of the compliance date of 02/03/22, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Plan of Correction
Deficiencies: 2
Feb 3, 2022
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified in a prior inspection report (Event ID XHV911).
Findings
The Plan of Correction addresses deficiencies referenced by tags F0000 and F609-D, with corrective actions attached and completion dates of 02/03/2022.
Deficiencies (2)
| Description |
|---|
| Deficiency referenced by tag F0000 |
| Deficiency referenced by tag F609-D |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Felicia Majewski | RN | Submitted the Plan of Correction to KDADS |
| Shirley Boltz | Contact for Plan of Correction assistance |
Inspection Report
Complaint Investigation
Census: 44
Deficiencies: 1
Jan 4, 2022
Visit Reason
The inspection was conducted as a complaint investigation (#KS00167942) regarding the facility's failure to submit a full investigation of a reportable occurrence to the appropriate state agency within five working days.
Findings
The facility failed to submit the completed investigation of an allegation of neglect involving Resident 1 to the state agency within the required timeframe. Resident 1 sustained a left knee fracture after falling from bed, and the investigation was completed but not timely reported as required by federal regulations.
Complaint Details
The complaint investigation #KS00167942 involved allegations of neglect related to Resident 1 who fell from bed and sustained a left knee fracture. The facility initiated an investigation but failed to submit the report to the state agency within five working days as required. The allegation was unsubstantiated, but the reporting requirement was not met.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to submit a full investigation of a reportable occurrence to the appropriate state agency within five working days as required. | SS=D |
Report Facts
Census: 44
BIMS score: 8
BIMS score: 10
Investigation submission timeframe: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aid (CNA) M | Named in the investigation as the staff member who was providing care when Resident 1 fell | |
| Administrative Staff A | Stated that the report needed to be submitted to the managing entity for review before sending to the state agency and acknowledged the delay |
Inspection Report
Re-Inspection
Deficiencies: 0
Nov 29, 2021
Visit Reason
A revisit survey was conducted on 11/29/21 to verify correction of all previous deficiencies cited on 09/16/21.
Findings
All deficiencies cited in the previous inspection have been corrected as of the compliance date of 10/31/21, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 0
Inspection Report
Complaint Investigation
Census: 41
Deficiencies: 14
Sep 16, 2021
Visit Reason
Health Licensure Resurvey and Complaint Investigation #KS00165206; KS00164912; KS00165557 conducted to assess compliance with care standards and regulatory requirements.
Findings
The facility was found deficient in multiple areas including failure to provide consistent bathing and ADL care, pressure ulcer prevention, restorative nursing care, accident hazard supervision, catheter care, tube feeding management, medication regimen review, medication error rate, food safety, infection prevention, and immunization documentation.
Complaint Details
Complaint investigation #KS00165206; KS00164912; KS00165557 conducted with findings of multiple deficiencies in care and regulatory compliance.
Severity Breakdown
SS=D: 8
SS=E: 5
SS=F: 1
Deficiencies (14)
| Description | Severity |
|---|---|
| Failure to provide consistent bathing for dependent residents R25 and R34, placing them at risk for poor hygiene and decreased psychosocial wellbeing. | SS=D |
| Failure to ensure pressure reducing ankle foot orthotic boots were placed on R1's lower extremities to prevent pressure ulcers. | SS=D |
| Failure to provide restorative nursing care to R24 to prevent decline in range of motion and functional ability. | SS=D |
| Failure to provide protective oversight and supervision for R6, who left the facility multiple times without proper assessment of safety and ability to operate a motor vehicle. | SS=D |
| Failure to provide appropriate catheter care for R20, including failure to keep catheter drainage bag off the floor and lack of privacy bag. | SS=D |
| Failure to maintain R1's head of bed at 45 degrees during tube feeding to prevent aspiration pneumonia. | SS=D |
| Failure of Consultant Pharmacist to identify irregularities in behavior monitoring for residents R16, R20, R25, and R34, risking unnecessary psychotropic medication use. | SS=E |
| Medication error rate of 40% for R1 due to crushing and mixing medications for PEG tube administration without physician order. | SS=E |
| Failure to administer physician ordered enoxaparin to R94, placing resident at risk for blood clots post-surgery. | SS=D |
| Failure to record medication room refrigerator temperatures for September 1-13, 2021. | SS=E |
| Failure to properly label and store food, and failure of dietary staff to follow proper hand hygiene and utensil cleaning practices, risking food contamination. | SS=E |
| Failure to follow infection prevention and control standards when distributing ice to resident rooms, including lack of hand hygiene and cross contamination risk. | SS=E |
| Infection Preventionist lacked required certification and specialized training in infection prevention and control. | SS=F |
| Failure to provide and document current influenza, pneumococcal, and coronavirus immunizations for residents R1, R11, R19, R25, and R32. | SS=E |
Report Facts
Medication error rate: 40
Medication administration observations: 30
Census: 41
Missed catheter care shifts: 78
Missed behavior monitoring shifts: 153
Missed medication behavior monitoring shifts: 153
Missed refrigerator temperature recordings: 13
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse E | Administrative Nurse | Interviewed regarding bathing, pressure ulcer prevention, medication administration, accident supervision, and infection control. |
| Administrative Nurse D | Administrative Nurse | Interviewed regarding bathing, pressure ulcer prevention, medication administration, accident supervision, infection control, and ice distribution. |
| Certified Nurse Aid M | Certified Nurse Aide | Interviewed regarding bathing, restorative care, catheter care, behavior monitoring, and medication administration. |
| Certified Nurse Aid N | Certified Nurse Aide | Observed and interviewed regarding ice distribution and infection control practices. |
| Certified Nurse Aid O | Certified Nurse Aide | Observed assisting resident with transfer and interviewed regarding bathing. |
| Contract Consultant HH | Contract Consultant Therapist | Interviewed regarding restorative therapy plan for resident R24. |
| Licensed Nurse G | Licensed Nurse | Interviewed regarding behavior monitoring and medication administration. |
| Certified Medication Aid R | Certified Medication Aid | Observed administering medication to resident R34. |
| Dietary Staff CC | Dietary Staff | Observed preparing pureed foods with improper hand hygiene and utensil cleaning. |
| Dietary Staff BB | Dietary Staff | Interviewed regarding food handling and storage practices. |
| Consultant Pharmacist GG | Consultant Pharmacist | Interviewed regarding medication review and behavior monitoring. |
Inspection Report
Plan of Correction
Deficiencies: 12
Sep 16, 2021
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a prior inspection conducted on 2021-09-16.
Findings
The plan outlines corrective actions for multiple deficiencies related to resident care plans, bathing preferences, pressure ulcer prevention, medication administration, behavioral monitoring, infection control, immunizations, and food safety. The facility commits to staff education, audits, and ongoing monitoring until compliance is achieved.
Severity Breakdown
D: 5
E: 6
F: 1
Deficiencies (12)
| Description | Severity |
|---|---|
| Bathing preferences not properly documented or followed | D |
| Pressure ulcer prevention care plans not updated or followed | D |
| Care plan updates related to resident's ability to operate a vehicle | D |
| Care plan updates regarding aspiration pneumonia prevention | D |
| Behavioral episodes not properly assessed or documented | E |
| Medication orders for combine and crush not verified before administration | E |
| Failure to verify accuracy of new orders for admits or re-admits | D |
| Inadequate documentation of refrigerator temperatures for medication storage | E |
| Failure to label thawed or opened food products and monitor expiration | E |
| Lack of proper hand-washing/sanitizing education for staff | E |
| Infection control prevention courses and certification not completed by DON | F |
| Immunization records not properly audited or updated | E |
Report Facts
Deficiencies cited: 12
Compliance completion date: Oct 31, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rodney Close | Administrator | Submitted the Plan of Correction |
Inspection Report
Complaint Investigation
Census: 40
Deficiencies: 1
Jul 1, 2021
Visit Reason
A complaint survey was conducted on 07/01/2021 for complaints #KSoo162952, KS00163360, and KS00160982. The allegations made in the complaints were not substantiated.
Findings
The facility failed to ensure one resident (R1) was free from accidents and injury when staff failed to provide necessary assistance with a Hoyer lift as directed by the care plan, resulting in two lacerations to R1's head. The facility provided education and skill checks to staff following the incident.
Complaint Details
The complaint survey was conducted for three complaints. The allegations were not substantiated and no noncompliance was found overall, but a specific deficiency was cited related to the accident involving resident R1.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure resident was free from accidents and injury when transferred with a Hoyer lift by only one staff member instead of two, resulting in two lacerations to the resident's head. | SS=D |
Report Facts
Census: 40
Number of residents reviewed for accidents: 3
Length of lacerations: 1.5
Length of lacerations: 2
Date of staff education: Jun 24, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA M | Certified Nurse Aide | Transferred resident R1 alone with Hoyer lift causing injury; received immediate education on failure to follow policy |
| CMA R | Certified Medication Aide | Stated staff had enough help on the floor and could get to all resident cares |
| Administrative Nurse D | Administrative Nurse | Stated resident safety was highest importance and confirmed skill check for CNA M |
| CNA N | Certified Nurse Aide | Stated Hoyer lift always required two staff members |
| Licensed Nurse G | Licensed Nurse | Stated staff should transfer with two staff members when using Hoyer lift |
| Consultant GG | Consultant | Stated Hoyer transfer should always be two-person transfer |
| Administrative Staff A | Administrative Staff | Stated expectation that Hoyer lift be used by two staff members without exception |
Inspection Report
Plan of Correction
Deficiencies: 1
Jun 24, 2021
Visit Reason
The plan of correction addresses a deficiency where the facility failed to ensure resident R1 was free from accidents and safety hazards due to improper transfer using a Hoyer lift by insufficient staff.
Findings
The facility staff failed to transfer resident R1 with two staff members when using the Hoyer lift, resulting in R1 sustaining two lacerations on the crown of his head. The facility completed nursing staff education and skill checks on the proper use of the Hoyer lift.
Deficiencies (1)
| Description |
|---|
| Failure to ensure resident R1 was free from accidents and safety hazards due to improper transfer with Hoyer lift by insufficient staff, resulting in lacerations. |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Sep 21, 2020
Visit Reason
A Targeted Infection Control Survey/COVID-19 Focused Survey was conducted by KDADS on behalf of the Centers for Medicare & Medicaid Services (CMS).
Findings
The facility was found to be in compliance with CMS and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19.
Inspection Report
Plan of Correction
Deficiencies: 0
Sep 21, 2020
Visit Reason
A Targeted Infection Control Survey/COVID-19 Focused Survey was conducted by KDADS on behalf of the Centers for Medicare & Medicaid Services (CMS) on 09/21/2020.
Findings
The facility was found to be in compliance with CMS and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19.
Inspection Report
Routine
Census: 41
Deficiencies: 0
Apr 9, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Centers for Medicare & Medicaid Services (CMS) to assess the facility's compliance with CMS and CDC recommended practices to prepare for COVID-19.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices for COVID-19 preparation.
Report Facts
Total residents: 41
Inspection Report
Plan of Correction
Deficiencies: 1
Apr 9, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Centers for Medicare & Medicaid Services (CMS) on 04/09/2020 to assess the facility's compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.
Deficiencies (1)
| Description |
|---|
| COVID-19 Focused Infection Control Survey compliance |
Inspection Report
Re-Inspection
Deficiencies: 0
Feb 5, 2020
Visit Reason
An onsite revisit survey was conducted on 02/05/2020 to verify correction of all previous deficiencies cited on 01/15/2020.
Findings
All deficiencies have been corrected as of the compliance date of 01/16/2020, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Re-Inspection
Deficiencies: 0
Feb 5, 2020
Visit Reason
An onsite revisit survey was conducted on 02/05/2020 for all previous deficiencies cited on 01/15/2020 to verify correction of deficiencies.
Findings
All deficiencies cited in the previous inspection have been corrected as of 01/16/2020, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Plan of Correction
Deficiencies: 1
Jan 15, 2020
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited in a prior inspection report dated 1/15/2020.
Findings
The plan outlines corrective actions related to behavior monitoring charting for residents receiving medications such as anti-psychotics, anti-anxiety, anti-depressants, and hypnotics, including monthly audits by the pharmacist and staff education to ensure compliance.
Deficiencies (1)
| Description |
|---|
| Inadequate behavior monitoring charting for residents receiving certain medications |
Report Facts
Compliance date: Jan 16, 2020
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rodney Close | Administrator | Submitted the Plan of Correction |
Inspection Report
Re-Inspection
Census: 42
Deficiencies: 1
Jan 15, 2020
Visit Reason
The inspection was a Non-Compliance Revisit to assess the facility's compliance with psychotropic medication regulations, specifically related to behavior monitoring for residents receiving such medications.
Findings
The facility failed to adequately document behavior monitoring for four residents (R1, R6, R25, and R39) who were receiving psychotropic medications, missing documentation for multiple shifts. This deficient practice posed a risk of unnecessary psychotropic medication administration and potential harmful side effects.
Severity Breakdown
SS=E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Lack of documentation for behavior monitoring for Residents 1, 6, 25, and 39 receiving psychotropic medications. | SS=E |
Report Facts
Census: 42
Shifts lacking behavioral monitoring for R1: 19
Shifts lacking behavioral monitoring for R6: 18
Shifts lacking behavioral monitoring for R25: 16
Shifts lacking behavioral monitoring for R39: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Stated staff had received training on behavior monitoring and acknowledged behaviors were not being documented every shift. | |
| Administrative Staff A | Stated staff receive training upon hire to ensure awareness of behavior monitoring expectations. |
Inspection Report
Plan of Correction
Deficiencies: 6
Nov 26, 2019
Visit Reason
This document is a Plan of Correction submitted by Medicalodge Leavenworth in response to deficiencies identified during the inspection conducted on 11/26/2019.
Findings
The plan addresses multiple deficiencies including updating diabetic care plans, behavior monitoring charting, fall risk interventions, oxygen and breathing treatment tubing sanitation, and notification of physicians regarding vital signs outside parameters. The facility outlines corrective actions, staff education, audits, and monitoring to achieve compliance by 12/20/2019.
Severity Breakdown
D: 4
E: 2
Deficiencies (6)
| Description | Severity |
|---|---|
| Failure to update diabetic residents' care plans to reflect proper diagnoses. | D |
| Inadequate behavior monitoring charting during staff shifts for residents at high risk for falls. | D |
| Failure to properly replace and date oxygen and breathing treatment tubing for residents. | D |
| Failure to notify physician and document response when blood pressure, pulse, or blood glucose are outside parameters. | E |
| Lack of behavior monitoring for residents receiving psychotropic medications. | D |
| Lack of behavior monitoring for residents receiving psychotropic medications. | E |
Report Facts
Compliance deadline: Dec 20, 2019
In-service training date: Dec 10, 2019
Number of residents sampled for behavior monitoring: 5
Duration of monitoring and education: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rodney Close | Administrator | Administrator involved in oversight and submission of Plan of Correction |
| Felicia Majewski | Person who added and modified the Plan of Correction |
Inspection Report
Complaint Investigation
Census: 45
Deficiencies: 9
Nov 26, 2019
Visit Reason
The inspection was a Health Resurvey and Complaint Investigation #KS00138878 conducted to assess compliance with regulatory requirements.
Findings
The facility failed to develop comprehensive care plans addressing diabetic care needs, failed to implement effective fall prevention interventions for residents at high risk, failed to ensure sanitary respiratory care equipment, and failed to ensure adequate behavior monitoring for residents on psychotropic medications. Additionally, the facility did not notify physicians of blood glucose, blood pressure, and pulse readings outside prescribed parameters.
Complaint Details
The inspection included a complaint investigation #KS00138878.
Severity Breakdown
SS=D: 4
SS=E: 5
Deficiencies (9)
| Description | Severity |
|---|---|
| Failed to develop a comprehensive care plan to address diabetic care needs for Resident 6. | SS=D |
| Failed to develop and implement appropriate interventions to prevent falls and potential injuries for Residents 1 and 39. | SS=D |
| Failed to ensure sanitary conditions for oxygen and nebulizer tubing to prevent infection for Resident 20. | SS=D |
| Failed to ensure the Clinical Pharmacist identified and reported lack of behavior monitoring for Residents 7, 6, 25, 1, and 39. | SS=E |
| Failed to notify the physician of blood pressures, pulses, and blood glucose levels outside of physician ordered parameters for Resident 6. | SS=D |
| Failed to adequately monitor for signs of anxiety and isolation for Resident 6. | SS=E |
| Failed to adequately monitor for signs of depression, abusive language, and wandering for Resident 25. | SS=E |
| Failed to adequately monitor behaviors for Resident 1 receiving psychotropic medications. | SS=E |
| Failed to adequately monitor behaviors for Resident 39 receiving psychotropic medications. | SS=E |
Report Facts
Deficiency cited: 9
Resident census: 45
Blood glucose levels: 454
Blood glucose levels: 535
Blood glucose levels: 518
Blood glucose levels: 455
Blood glucose levels: 411
Blood pressure: 98
Pulse: 53
Behavior monitoring missing shifts: 16
Behavior monitoring missing shifts: 23
Behavior monitoring missing shifts: 22
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide M | Certified Nurse Aide | Described behavior monitoring and fall risk procedures. |
| Licensed Nurse G | Licensed Nurse | Described care plan initiation, behavior monitoring, and notification procedures. |
| Administrative Nurse D | Administrative Nurse | Described care plan initiation, behavior monitoring, fall risk assessment, and documentation procedures. |
Inspection Report
Re-Inspection
Deficiencies: 9
Jan 25, 2019
Visit Reason
An offsite revisit survey was conducted on 01/25/2019 for all previous deficiencies cited on 11/14/2018 to verify correction of prior deficiencies.
Findings
All deficiencies cited in the previous inspection have been corrected as of the compliance date of 11/27/2018, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Severity Breakdown
E: 6
D: 2
F: 1
Deficiencies (9)
| Description | Severity |
|---|---|
| Accuracy of Assessments - The assessment must accurately reflect the resident's status. | E |
| Care Plan Timing and Revision - Comprehensive care plans must be developed within 7 days after assessment and prepared by an interdisciplinary team including physician, nurse, nurse aide, food and nutrition staff, and resident participation when practicable. | E |
| Free of Accident Hazards/Supervision/Devices - The resident environment must be free of accident hazards and residents must receive adequate supervision and assistance devices to prevent accidents. | D |
| RN 8 Hrs/7 days/Wk, Full Time DON - Facility must use a registered nurse for at least 8 consecutive hours a day, 7 days a week and designate a full-time director of nursing. | D |
| Drug Regimen Review, Report Irregular, Act On - Monthly drug regimen review by licensed pharmacist must include review of medical chart and reporting of irregularities to physician and facility staff with documented actions. | E |
| Drug Regimen is Free from Unnecessary Drugs - Each resident's drug regimen must be free from unnecessary drugs including excessive dose, duration, lack of monitoring, or adverse consequences. | E |
| Free from Unnecessary Psychotropic Meds/PRN Use - Psychotropic drugs must be used only when necessary, with gradual dose reductions, and PRN orders limited to 14 days unless documented otherwise. | E |
| Drinks Available to Meet Needs/Preferences/Hydration - Facility must provide drinks including water consistent with resident needs and preferences to maintain hydration. | F |
| Frequency of Meals/Snacks at Bedtime - Facility must provide at least three meals daily at regular times and suitable nourishing alternative meals/snacks at non-traditional times consistent with resident care plans. | E |
Inspection Report
Plan of Correction
Deficiencies: 10
Nov 27, 2018
Visit Reason
This document is a Plan of Correction submitted by Medicalodges Leavenworth in response to deficiencies identified in a prior inspection, outlining corrective actions to achieve substantial compliance with federal Medicare/Medicaid requirements.
Findings
The plan addresses multiple deficiencies related to resident transfer notifications, MDS accuracy, care plan updates, fall risk management, RN coverage, bowel movement protocols, medication management, hydration, snack provision, and resident safety systems. The facility commits to education, audits, and ongoing monitoring through QAPI until substantial compliance is maintained.
Deficiencies (10)
| Description |
|---|
| Resident transfer notification requirements not met |
| MDS documentation inaccuracies |
| Care plans not updated to meet resident needs |
| Falls management and neurological checks deficiencies |
| RN coverage schedule not meeting regulations |
| Bowel movement monitoring and intervention deficiencies |
| Medication DISCUS policy not followed |
| Inadequate provision of fresh water |
| Inadequate provision of snacks between meals |
| Resident call light system functionality issues |
Report Facts
Audit frequency: 4
Audit frequency: 2
Audit sample size: 3
Audit sample size: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rodney Close | Administrator | Submitted the Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance |
Inspection Report
Complaint Investigation
Census: 45
Deficiencies: 1
Nov 14, 2018
Visit Reason
The inspection was conducted as a Health Licensure Resurvey and Complaint Investigations KS00134297 and KS00129748.
Findings
The facility failed to maintain an operable call light system for one of four days of the facility review, with observations confirming call lights did not activate audible or visual signals at the nursing station. Residents complained about call lights not being answered timely, and maintenance staff acknowledged difficulties in keeping call lights operational.
Complaint Details
The visit was complaint-related as indicated by the Health Licensure Resurvey and Complaint Investigations KS00134297 and KS00129748. Resident council review included complaints from at least 10 residents about call lights not being answered in a timely manner.
Severity Breakdown
SS=E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to maintain an operable call light system ensuring residents could contact nursing staff. | SS=E |
Report Facts
Census: 45
Sample size: 34
Days call light system failed: 1
Resident complaints: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff W | Maintenance staff who acknowledged inoperable call lights and described maintenance efforts. | |
| Administrative staff D | Administrative staff who stated the facility did not have a specific call light policy but ensured routine maintenance. |
Inspection Report
Plan of Correction
Deficiencies: 1
Mar 6, 2018
Visit Reason
A complaint survey was conducted on 3/6/18 for complaint #KS00126162 and #KS00126743.
Findings
The allegations made in the complaints were not substantiated. No noncompliance was found. The facility is in compliance with all regulations surveyed.
Complaint Details
The allegations made in the complaints were not substantiated.
Deficiencies (1)
| Description |
|---|
| No noncompliance was found. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Mar 6, 2018
Visit Reason
A complaint survey was conducted on 3/6/18 for complaint #KS00126162 and #KS00126743.
Findings
The allegations made in the complaints were not substantiated. No noncompliance was found. The facility is in compliance with all regulations surveyed.
Complaint Details
The allegations made in the complaints were not substantiated.
Inspection Report
Complaint Investigation
Deficiencies: 0
Mar 6, 2018
Visit Reason
A complaint survey was conducted on 3/6/18 for complaint #KS00126162 and #KS00126743.
Findings
The allegations made in the complaints were not substantiated. No noncompliance was found. The facility is in compliance with all regulations surveyed.
Complaint Details
The allegations made in the complaints were not substantiated.
Inspection Report
Follow-Up
Deficiencies: 15
May 26, 2017
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 have been corrected.
Findings
All previously cited deficiencies were corrected as of the revisit date, with each correction completed and documented on 05/26/2017.
Deficiencies (15)
| Description |
|---|
| Deficiency related to regulation 483.40(d) |
| Deficiency related to regulation 483.10(i)(2) |
| Deficiency related to regulation 483.20(b)(1) |
| Deficiency related to regulations 483.20(d);483.21(b)(1) |
| Deficiency related to regulations 483.10(c)(2)(i-ii,iv,v)(3),483.21(b)(2) |
| Deficiency related to regulation 483.24(a)(1) |
| Deficiency related to regulations 483.25(e)(1)-(3) |
| Deficiency related to regulations 483.25(c)(2)(3) |
| Deficiency related to regulations 483.45(d)(e)(1)-(2) |
| Deficiency related to regulations 483.80(d)(1)(2) |
| Deficiency related to regulations 483.35(a)(1)-(4) |
| Deficiency related to regulations 483.35(g)(1)-(4) |
| Deficiency related to regulations 483.60(d)(1)(2) |
| Deficiency related to regulations 483.45(c)(1)(3)-(5) |
| Deficiency related to regulations 483.80(a)(1)(2)(4)(e)(f) |
Inspection Report
Plan of Correction
Deficiencies: 15
May 3, 2017
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited in a prior inspection, outlining corrective actions to achieve substantial compliance with federal Medicare/Medicaid requirements.
Findings
The plan details corrective actions for multiple deficiencies including care plan revisions, environmental repairs, staff education, audits, and monitoring processes to ensure compliance in areas such as PASRR screening, oral care, toileting plans, medication administration, vaccination offerings, staffing levels, and housekeeping.
Severity Breakdown
D: 9
E: 5
F: 1
C: 1
Deficiencies (15)
| Description | Severity |
|---|---|
| Referral and review for Level II PASRR for resident #4 | D |
| Drywall repair and environmental maintenance | E |
| Timely completion and submission of MDS for resident #50 | D |
| Care plan revisions for oral care needs for residents #41 and #1 | D |
| Toileting plan and voiding diary for resident #46 | D |
| Hygiene and grooming care plan revisions and refusals | D |
| Incontinence care plans and education | D |
| Restorative assessment and care plan updates for resident #1 | D |
| Care plans for targeted behavior monitoring and medication administration audit | D |
| Influenza and pneumococcal vaccination offerings and documentation | E |
| Weekly resident interviews regarding staffing levels | F |
| BIPA posting education and compliance audits | C |
| Education on kitchen thermometer use and food temperature monitoring | E |
| Care plan revisions for behavior monitoring and medication administration audits | D |
| Housekeeping and nursing staff education on cleaning agents and room cleaning audits | E |
Report Facts
Complete dates for corrective actions: May 26, 2017
Complete date for initial plan submission: May 3, 2017
Inspection Report
Re-Inspection
Deficiencies: 1
Apr 26, 2017
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 an '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 accepted, resulting in a finding of substantial compliance effective May 26, 2017.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Most serious deficiencies found were an 'F' level deficiency, widespread, constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy. | F |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure Certification & Enforcement Manager | Signed letter regarding survey findings and plan of correction acceptance. |
Inspection Report
Census: 36
Deficiencies: 13
Apr 26, 2017
Visit Reason
The inspection was a Health Resurvey and Complaint Investigation covering multiple complaint investigation numbers.
Findings
The facility was cited for multiple deficiencies including failure to provide medically-related social services for a resident needing PASRR follow-up, failure to maintain a safe and orderly interior due to maintenance issues, failure to complete timely comprehensive assessments, failure to develop comprehensive care plans, failure to update care plans for urinary incontinence, failure to provide adequate assistance with activities of daily living including bathing and personal hygiene, failure to provide range of motion services, failure to monitor behavior and bowel movements for residents on psychotropic medications, failure to document medication administration, failure to obtain vaccine consents, insufficient nursing staff, failure to post and retain nurse staffing information, failure to maintain safe food temperatures, and failure to utilize infection control precautions properly.
Severity Breakdown
SS=D: 7
SS=E: 4
SS=F: 1
SS=C: 1
Deficiencies (13)
| Description | Severity |
|---|---|
| Failure to provide medically-related social services to attain or maintain the highest practicable well-being for a resident needing PASRR Level II follow-up. | SS=D |
| Failure to maintain a safe, orderly, and comfortable interior through preventative maintenance services on 2 of 2 halls. | SS=E |
| Failure to complete an Admission Minimum Data Set (MDS) comprehensive assessment within the required timeframe for one resident. | SS=D |
| Failure to provide a comprehensive, person-centered care plan for 3 residents. | SS=D |
| Failure to update the care plan for urinary incontinence for one resident. | SS=D |
| Failure to ensure two residents did not receive baths/showers and personal hygiene as care planned. | SS=D |
| Failure to provide range of motion services for one resident reviewed for range of motion services. | SS=D |
| Failure to provide behavior monitoring for 2 residents, bowel monitoring for 1 resident, and ensure medication administration for 1 resident of 5 sampled for unnecessary medications. | SS=D |
| Failure to provide documentation of influenza and pneumococcal vaccine consent forms for 5 of 7 sampled residents. | SS=E |
| Failure to provide sufficient nursing staff to provide nursing services to maintain the highest practicable well-being of each resident for 4 of 4 days on site of the survey. | SS=F |
| Failure to retain daily nurse staffing information for a period of 18 months and failure to document required data on the daily posting of nurse staffing information. | SS=C |
| Failure to maintain adequate safe food temperatures for 1 of 1 test food trays. | SS=E |
| Failure to utilize precautions to minimize transmission of infection on 1 of 2 halls. | SS=E |
Report Facts
Deficiencies cited: 13
Residents sampled: 18
Days missing nurse staffing records: 41
Days with missing medication documentation: 16
Food temperature: 127
Food temperature: 122.1
Food temperature: 122.5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Administrative Nursing Staff | Acknowledged missing nurse staffing records and missing documentation in medication administration records. |
| Staff H | Licensed Nursing Staff | Confirmed lack of medication documentation and discussed care plan and behavior monitoring. |
| Staff P | Direct Care Staff | Provided information on resident care, bowel movement charting, and behavior monitoring. |
| Staff JJ | Consultant Pharmacist | Noted missing documentation on medication administration and behavior monitoring; sent recommendations to Director of Nursing. |
| Staff X | Housekeeping Staff | Sprayed disinfectant but unaware of required kill time. |
| Staff Y | Housekeeping Supervisory Staff | Stated disinfectant kill time was 10 minutes. |
| Staff EE | Dietary Management Staff | Checked room tray temperatures but did not keep a log. |
Inspection Report
Life Safety
Deficiencies: 1
Oct 13, 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 an '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 enforcement remedies were recommended due to failure to achieve substantial compliance.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Deficiencies cited at 'F' level with no harm but potential for more than minimal harm that is not immediate jeopardy. | F |
Report Facts
Effective date for denial of payments: Jan 13, 2016
Provider agreement termination date: Apr 13, 2017
Plan of correction submission timeframe: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure Certification & Enforcement Manager | Signed the report and referenced as contact for enforcement and certification. |
| Brenda McNorton | Director of Fire Prevention Division | Contact for Informal Dispute Resolution process. |
Inspection Report
Follow-Up
Deficiencies: 0
Oct 28, 2015
Visit Reason
This post-certification revisit was conducted to verify that deficiencies previously reported on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
The revisit confirmed that all previously cited deficiencies were corrected as of the revisit date, with corrections documented for multiple regulatory requirements.
Report Facts
Deficiencies corrected: 9
Inspection Report
Re-Inspection
Deficiencies: 1
Oct 28, 2015
Visit Reason
This revisit report documents the correction of deficiencies previously reported during an earlier survey conducted on 2015-10-05.
Findings
The report confirms that the previously identified deficiency under regulation 28-39-158(a) with ID prefix S0600 was corrected as of 2015-10-28.
Deficiencies (1)
| Description |
|---|
| Deficiency under regulation 28-39-158(a) previously cited |
Report Facts
Date of previous survey: Oct 5, 2015
Inspection Report
Re-Inspection
Deficiencies: 1
Oct 5, 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 'F' level deficiencies, widespread, 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 and plan of correction.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| 'F' level deficiencies, widespread, constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy. | F |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed the enforcement decision letter |
Inspection Report
Complaint Investigation
Census: 51
Deficiencies: 9
Oct 5, 2015
Visit Reason
The inspection was conducted as a Health Resurvey and Complaint Investigation covering multiple complaint numbers.
Findings
The facility was found deficient in multiple areas including housekeeping and maintenance services, coordination of hospice care, nutrition status maintenance, unnecessary drug monitoring, sanitary food procurement and preparation, pharmaceutical service accuracy, equipment safety, environmental safety, and quality assessment committee compliance.
Complaint Details
The inspection was triggered by multiple complaints as indicated by complaint investigation numbers #91128, #91050, #86772, #85565, #85002.
Severity Breakdown
Level D: 3
Level E: 2
Level F: 4
Deficiencies (9)
| Description | Severity |
|---|---|
| Failed to provide a sanitary and comfortable environment with stained floor tile, exposed drywall, stains in resident sinks, and standing water in bathrooms. | Level E |
| Failed to coordinate care with hospice services for a resident receiving hospice care. | Level D |
| Failed to prevent weight loss for a resident due to inadequate nutritional assessment and intervention. | Level D |
| Failed to monitor behavior for residents receiving antipsychotic medications. | Level F |
| Failed to maintain a clean and sanitary kitchen environment including unlabeled and outdated food items and paint chipping over food prep area. | Level D |
| Failed to accurately transcribe a medication order for a resident receiving mood altering medications. | Level E |
| Failed to maintain safe environment due to crumbed cement patches on sidewalk and unsecured metal handrail. | Level F |
| Failed to provide a safe, functioning, and sanitary environment as evidenced by occluded ice machine air gap with waste water and foul odor. | Level F |
| Failed to have a Quality Assessment and Assurance Committee that met quarterly with medical director attendance. | Level F |
Report Facts
Census: 51
Sample size: 17
Weight loss: 9.4
Medication dosage: 2250
Medication dosage change: 750
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff X | Maintenance Staff | Acknowledged stains, leaks, and maintenance issues. |
| Licensed Staff J | Licensed Nurse | Provided information on hospice nurse visits and resident care. |
| Direct Care Staff S | Unaware of hospice home health aide schedule. | |
| Direct Care Staff T | Reported hospice visits and care supplies. | |
| Registered Dietician DD | Registered Dietician | Assessed resident nutrition and recommended diet changes. |
| Administrative Licensed Staff D | Administrative Licensed Nurse | Expected staff to inform nursing of weight loss and care coordination. |
| Direct Care Staff P | Reported resident's physical and verbal altercations. | |
| Direct Care Staff Q | Documented resident behaviors and medication refusals. | |
| Licensed Staff I | Licensed Nurse | Reported resident behavior monitoring and nurse documentation. |
| Administrative Staff A | Administrator | Acknowledged QAA committee meeting attendance issues. |
| Administrative Staff B | Administrative Staff | Acknowledged lack of nurse charting on behavior documentation. |
| Consultant Staff II | Consultant | Expected appropriate monitoring and documentation of resident behaviors. |
| Pharmacy Consultant JJ | Pharmacy Consultant | Provided opinion on medication dosing. |
| Pharmacy Consultant II | Pharmacy Consultant | Provided opinion on medication formulation preferences. |
Inspection Report
Follow-Up
Deficiencies: 1
Sep 23, 2015
Visit Reason
This visit was a post-certification revisit to verify correction of previously cited deficiencies from the survey completed on 2015-08-24.
Findings
The report shows that the previously cited deficiency with ID prefix F0323 related to regulation 483.25(h) was corrected as of 2015-09-23.
Deficiencies (1)
| Description |
|---|
| Deficiency previously cited under regulation 483.25(h) with ID prefix F0323 |
Report Facts
Deficiencies corrected: 1
Inspection Report
Abbreviated Survey
Deficiencies: 1
Aug 24, 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 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 which was accepted, and the facility was found to be in substantial compliance based on the credible allegation of compliance and the plan of correction.
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Most serious deficiency found was a 'D' level deficiency constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy. | D |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary Jane Kennedy | Complaint Coordinator | Named as the contact person regarding the survey findings and plan of correction. |
Inspection Report
Complaint Investigation
Census: 55
Deficiencies: 1
Aug 24, 2015
Visit Reason
The inspection was conducted as a complaint investigation (#KS00078988 and #KS00089645) focusing on the facility's failure to provide effective interventions to prevent elopement for a resident at risk.
Findings
The facility failed to monitor the function of the wanderguard bracelet, failed to place the resident's photo in the elopement book per facility policy, and failed to ensure secure doors and alarms for a cognitively impaired, independently mobile resident with a history of exit seeking, who was found outside the building on facility property.
Complaint Details
The complaint investigation revealed that resident #1, who had cognitive deficits and was at high risk for elopement, was found outside the facility approximately 180 feet from the door he/she exited. The facility failed to monitor the wanderguard bracelet consistently, failed to secure doors properly, and did not have the resident's photo in the elopement book as required.
Severity Breakdown
SS=E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to provide effective interventions to prevent elopement for 1 of 3 residents sampled at risk for elopement, including failure to monitor wanderguard bracelet function and secure facility doors. | SS=E |
Report Facts
Census: 55
Residents sampled: 13
Residents at risk for elopement: 10
Distance resident found outside: 180
Temperature: 81
BIMS score: 4
Wanderguard monitoring gap: 136
Inspection Report
Plan of Correction
Deficiencies: 1
Jul 21, 2015
Visit Reason
This Plan of Correction document responds to deficiencies identified following a complaint investigation related to resident safety and elopement risks, specifically addressing an incident on July 21, 2015.
Findings
The facility implemented multiple corrective actions to ensure resident safety, including securing exit doors with alarms, hourly door checks, staff training on alarm response, weekly elopement drills, and monitoring by the Quality Assurance Committee. Resident #1 was moved closer to the nurse's station and placed on 15-minute safety checks following the incident.
Complaint Details
This Plan of Correction addresses deficiencies identified from a complaint investigation triggered by an incident on July 21, 2015 involving Resident #1 and exit door safety.
Deficiencies (1)
| Description |
|---|
| Failure to ensure resident environment remained free of accident hazards and adequate supervision to prevent accidents, specifically related to exit door alarms and elopement risk. |
Report Facts
Date of incident: Jul 21, 2015
Date corrective actions to be completed: Sep 23, 2015
Date Plan of Correction review: Sep 11, 2015
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Todd Burford | Administrator | Submitted the Plan of Correction |
Inspection Report
Life Safety
Deficiencies: 1
Jun 10, 2015
Visit Reason
A Life Safety Code survey was conducted by the State Fire Marshal's Office to determine if the facility was in compliance with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies to be an 'F' level deficiency, widespread, with no harm but with potential for more than minimal harm that is not immediate jeopardy.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility found to have an 'F' level deficiency, widespread, with no harm but potential for more than minimal harm that is not immediate jeopardy. | F |
Report Facts
Effective date for denial of payments: Sep 10, 2015
Provider agreement termination date: Dec 10, 2015
Plan of correction submission timeframe: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Brenda McNorton | Director of Fire Prevention Division | Contact for Informal Dispute Resolution process. |
| Irina Strakhova | Enforcement Coordinator | Signed the enforcement letter. |
Inspection Report
Follow-Up
Deficiencies: 4
Sep 17, 2014
Visit Reason
This visit was a post-certification revisit to verify correction of previously cited deficiencies from the survey completed on 2014-06-19.
Findings
The report shows that all previously cited deficiencies identified by regulation numbers 483.25(a)(2), 483.25(d), 483.60(a),(b), and 483.75(o)(1) were corrected as of 2014-09-17.
Deficiencies (4)
| Description |
|---|
| Deficiency related to regulation 483.25(a)(2) |
| Deficiency related to regulation 483.25(d) |
| Deficiency related to regulation 483.60(a),(b) |
| Deficiency related to regulation 483.75(o)(1) |
Report Facts
Deficiencies corrected: 4
Inspection Report
Plan of Correction
Deficiencies: 4
Sep 17, 2014
Visit Reason
This Plan of Correction document responds to deficiencies cited in a prior inspection, outlining corrective actions to achieve substantial compliance by 09/17/2014.
Findings
The plan addresses deficiencies related to resident care plans, grooming and nail care, perineal care after incontinent episodes, and medication administration documentation and procedures. The facility commits to staff education, skills checks, audits, and ongoing monitoring by the Quality Assurance Committee.
Severity Breakdown
D: 3
F: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Resident #13's care plan and profile not reflecting behaviors and choices regarding clothes and nail care. | D |
| Incomplete perineal care after incontinent episodes for residents #13, #16, and others. | D |
| Medications administered lacked proper time and initials documentation on MAR. | D |
| Root cause analysis and ongoing action plan needed to ensure substantial compliance for F311, F315, and F425 deficiencies. | F |
Report Facts
Complete date for correction: Sep 17, 2014
Audit date: Aug 22, 2014
Inspection Report
Re-Inspection
Deficiencies: 1
Aug 18, 2014
Visit Reason
A first revisit to a Health recertification survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid.
Findings
The survey found the most serious deficiency to be an "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, resulting in a finding of substantial compliance effective September 17, 2014.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Most serious deficiency found to be an "F" level deficiency, widespread, constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy. | F |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Named as Enforcement Coordinator in the report letter. |
Inspection Report
Re-Inspection
Deficiencies: 1
Aug 18, 2014
Visit Reason
The revisit was conducted on August 18, 2014, to verify that the facility had achieved and maintained compliance with Federal requirements following the June 19, 2014 Health survey.
Findings
The revisit found the most serious deficiency to be an 'F' level deficiency, widespread, indicating the facility was not in substantial compliance. Enforcement remedies including denial of payment for new Medicare/Medicaid admissions and recommendation for termination of provider agreement were imposed.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Most serious deficiency found was an 'F' level deficiency, widespread | F |
Report Facts
Effective date of denial of payment: Sep 19, 2014
Recommended termination date: Dec 19, 2014
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Darin Cizerle | Administrator | Named as facility administrator in relation to the inspection |
| Irina Strakhova | Enforcement Coordinator | Contact person for questions concerning the instructions in the letter |
Inspection Report
Follow-Up
Deficiencies: 0
Aug 18, 2014
Visit Reason
This is a post-certification revisit to verify that previously cited deficiencies have been corrected as per the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
All previously reported deficiencies identified by their regulation numbers and prefix codes were corrected as of the revisit date.
Report Facts
Deficiencies corrected: 14
Inspection Report
Re-Inspection
Deficiencies: 1
Aug 18, 2014
Visit Reason
This report documents a revisit inspection to verify that previously reported deficiencies have been corrected at the facility.
Findings
The revisit report confirms that the previously identified deficiency under regulation 28-39-158(a) was corrected as of the revisit date.
Deficiencies (1)
| Description |
|---|
| Deficiency under regulation 28-39-158(a) previously cited and corrected. |
Inspection Report
Re-Inspection
Census: 54
Deficiencies: 4
Aug 18, 2014
Visit Reason
This inspection was a Non-Compliance Revisit to assess correction of previously cited deficiencies related to resident care and facility operations.
Findings
The facility failed to provide necessary services to maintain good personal hygiene for a resident, failed to provide complete perineal care for incontinent residents, and failed to ensure accurate medication administration documentation. Additionally, the quality assurance committee did not adequately address and implement plans to correct identified deficiencies.
Severity Breakdown
SS=D: 3
SS=F: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to provide necessary services to maintain good personal hygiene for a resident, including cleaning fingernails and providing bath sheets. | SS=D |
| Failure to provide complete perineal care to all areas in contact with urine and/or feces for incontinent residents. | SS=D |
| Failure to document exact time of medication delivery during medication pass for one resident, resulting in unsafe medication administration. | SS=D |
| Failure to maintain a quality assurance committee that develops and implements appropriate plans of action to correct identified quality deficiencies. | SS=F |
Report Facts
Census: 54
Residents sampled: 7
Medications given at one time: 12
Time between resident checks: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Direct care staff O | Observed assisting resident with hygiene and incontinent care; failed to clean fingernails and provide complete perineal care. | |
| Administrative nursing staff D | Interviewed regarding care standards and policies; revealed staff should clean all areas in contact with urine and apply barrier cream. | |
| Licensed nursing staff H | Interviewed about medication administration and resident care. | |
| Direct care staff P | Assisted resident with toileting and bed transfer; interviewed about care plan adherence. | |
| Direct care staff R | Assisted with resident care and incontinent care; failed to change gloves appropriately. | |
| Direct care staff T | Prepared morning medications for a resident. | |
| Administrative staff A | Reported on quality assurance committee meetings. |
Inspection Report
Plan of Correction
Deficiencies: 16
Jul 2, 2014
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a prior inspection, outlining corrective actions and timelines to achieve substantial compliance.
Findings
The Plan of Correction details multiple deficiencies including issues with staff training on abuse and neglect policies, resident dignity, call light accessibility, environmental repairs, care plan accuracy, medication administration, and safety hazards. The facility outlines specific corrective actions, staff in-service training, environmental repairs, and ongoing monitoring to achieve substantial compliance by July 19, 2014.
Severity Breakdown
E: 6
D: 6
F: 2
: 1
Deficiencies (16)
| Description | Severity |
|---|---|
| Department heads to be in-serviced on abuse, neglect, and exploitation policy; criminal background checks to be documented for new hires. | E |
| Staff to call resident #16 by preferred name; name preferences to be gathered and reviewed quarterly. | D |
| Call lights to be within reach for residents #20 and #13; ongoing monitoring of call light accessibility. | D |
| Repair or replacement of stained, cracked, or chipped tiles; repair of door frames, door jams, walls, and handrails; cleaning and flame retardant treatment of carpeting. | E |
| Staff in-service on care plan process and revisions; care plans updated for residents with incidents. | D |
| Staff in-service on incontinence care and timely repositioning; charge nurse responsible for pericare compliance. | D |
| Falls for residents #5 and #13 investigated; individualized interventions implemented; chemical storage secured. | E |
| Repair of metal bracket with jagged edges; weekly door lock checks. | — |
| Behavior monitoring and documentation for residents on psychotropic medications; staff in-service on behavior sheets. | E |
| Staff in-service on medication administration timing and procedures; random weekly audits by Director of Nursing. | D |
| Cleaning and sanitation of dietary equipment; staff in-service on handling and dating of food items. | F |
| Consultant pharmacist to review psychotropic medication monitoring; follow-up on pharmacist recommendations. | E |
| In-service on labeling drugs and biologicals; auditing of expiration dates and opened medications. | D |
| Repair of call lights; weekly checks and staff in-service on maintenance requisitions. | E |
| Securing metal handrails and sidewalk repair with periodic checks. | D |
| Pest control contract established for weekly treatments; ongoing monitoring and resident council consultation. | F |
Report Facts
Plan of Correction completion date: Jul 19, 2014
Dietary manager test date: Jul 15, 2014
Sidewalk repair expected completion: 45
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kathleen Lantz | Regional Vice President | Submitted the Plan of Correction to KDADS |
Inspection Report
Enforcement
Deficiencies: 1
Jun 19, 2014
Visit Reason
A Health survey was conducted by the Kansas Department for Aging and Disability Services 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 most serious deficiencies in the facility to be at an "F" level, resulting in enforcement remedies including denial of payment for new Medicare admissions effective September 19, 2014, until substantial compliance is achieved or the provider agreement is terminated.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Most serious deficiencies found at an "F" level | F |
Report Facts
Denial of payment effective date: Sep 19, 2014
Termination recommendation date: Dec 19, 2014
Civil Money Penalty threshold: 5000
IDR submission timeframe: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Contact person for questions concerning the instructions contained in the letter |
Inspection Report
Complaint Investigation
Census: 57
Deficiencies: 14
Jun 19, 2014
Visit Reason
The inspection was a Health Resurvey and Complaint Investigation to assess compliance with regulations related to abuse/neglect policies, dignity and respect, reasonable accommodation, housekeeping, care planning, catheter use, accident hazards, medication regimen, food sanitation, drug regimen review, medication storage, call light system, environment safety, and pest control.
Findings
The facility was found deficient in multiple areas including failure to implement abuse/neglect screening policies, failure to enhance resident dignity, inaccessible call lights, unsanitary housekeeping conditions, incomplete care plans, inadequate incontinence care, failure to investigate falls and follow post-fall recommendations, unsafe environment hazards, ineffective pest control, medication errors, failure to monitor medication effectiveness, improper medication storage, and malfunctioning call light systems.
Complaint Details
The inspection included a complaint investigation #KS00074016.
Severity Breakdown
Level E: 7
Level D: 3
Level F: 4
Deficiencies (14)
| Description | Severity |
|---|---|
| Failed to implement Abuse, Neglect and Exploitation policy requiring screening of employees; missing criminal background checks and reference checks in personnel files. | Level E |
| Failed to enhance dignity of resident #16; staff used inappropriate pet names and failed to document preferred names. | Level D |
| Failed to provide accessible call lights for residents #20 and #13; call lights were out of reach or improperly placed. | Level E |
| Failed to maintain a comfortable, sanitary, and clean environment; multiple floor tiles stained, chipped, door frames chipped, holes in walls and shower rooms, rust around faucets. | Level D |
| Failed to develop comprehensive care plan for resident #5; care plan lacked interventions related to falls and safety. | Level D |
| Failed to provide incontinence care every 2 to 3 hours for resident #30; resident left in saturated brief for nearly 4 hours. | Level E |
| Failed to investigate falls for residents #5 and #13; failed to follow post-fall recommendations for resident #5; unsafe environment hazards including unsecured chemicals, unlocked exit door, and exposed jagged metal bracket. | Level E |
| Failed to provide consistent monitoring for medication effectiveness for residents #38, #82, #13, #58, and #61 receiving psychotropic and other medications; behavior monitoring sheets incomplete or not linked to medications. | Level E |
| Failed to administer medication (Omeprazole) to resident #9 as ordered (not given 30 minutes before meals). | Level F |
| Medication error: resident #52 received calcium antacid instead of ordered Calcium plus Vitamin D. | Level F |
| Failed to properly date opened insulin vial and failed to dispose of expired medications in medication cart and medication room. | Level E |
| Failed to maintain functioning call light system; 5 resident room call lights did not work or light up at panel. | Level D |
| Failed to provide a safe and functional environment; unsecured metal handrails outside, disrepair of cement walkways and crumbled curb near entrance. | Level F |
| Failed to maintain effective pest control program; live spiders and beetles observed in medication room, dining room, service hallway, and conference room; door gap allowing pest entry not repaired. | Level F |
Report Facts
Medication administrations observed: 26
Residents with cognitive impairment: 16
Residents reviewed for unnecessary medications: 5
Residents reviewed for medication errors: 2
Residents with call light failures: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative staff A | Interviewed regarding background checks, fall investigations, and call light maintenance. | |
| Administrative staff B | Interviewed regarding background checks and employee screening. | |
| Administrative nursing staff D | Interviewed regarding care plans, fall investigations, medication monitoring, and behavior monitoring. | |
| Licensed nursing staff H | Interviewed regarding resident dignity, medication monitoring, and sleep monitoring. | |
| Licensed nursing staff I | Interviewed regarding resident dignity, medication monitoring, and medication errors. | |
| Licensed nursing staff K | Interviewed regarding incontinence care, fall risk, and medication monitoring. | |
| Licensed nursing staff M | Interviewed regarding behavior monitoring sheets and medication monitoring. | |
| Consultant pharmacist KK | Interviewed regarding medication regimen review and behavior monitoring. | |
| Dietary manager DD | Interviewed regarding food storage and sanitation. | |
| Maintenance supervisor Y | Interviewed regarding environmental hazards, call light maintenance, and pest control. | |
| Housekeeping supervisor Z | Interviewed regarding housekeeping and kitchenette cleaning. |
Inspection Report
Follow-Up
Deficiencies: 2
Aug 16, 2013
Visit Reason
This is a post-certification revisit conducted to verify that previously reported deficiencies have been corrected as indicated on the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
The revisit confirmed that the deficiencies previously cited under regulations 483.20(k)(3)(i) and 483.25(d) were corrected as of 08/16/2013.
Deficiencies (2)
| Description |
|---|
| Deficiency related to regulation 483.20(k)(3)(i) |
| Deficiency related to regulation 483.25(d) |
Report Facts
Deficiencies corrected: 2
Inspection Report
Complaint Investigation
Census: 58
Deficiencies: 6
Jul 24, 2013
Visit Reason
The inspection was conducted as a complaint investigation based on complaint investigation numbers #KS65430 and #KS64575.
Findings
The facility failed to provide a temporary care plan for one resident with a Foley catheter and pressure ulcers, and failed to provide documentation and policy for Foley catheter care for two residents. The clinical records lacked evidence of catheter care and medical justification for catheter use.
Complaint Details
The visit was triggered by complaint investigations #KS65430 and #KS64575. The findings included failure to provide temporary care plans and proper Foley catheter care documentation and policies.
Severity Breakdown
SS=D: 2
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to provide a temporary care plan for a resident with Foley catheter and pressure ulcers. | SS=D |
| Failed to provide documentation of Foley catheter care for two residents. | SS=D |
| Failed to provide a policy and procedure for temporary care plans. | — |
| Failed to provide a policy and procedure for Foley catheter care. | — |
| Clinical record lacked evidence of catheter care in April 2013. | — |
| Clinical record lacked medical justification for the use of the catheter. | — |
Report Facts
Census: 58
Residents sampled: 3
Foley catheter residents with care documentation issues: 2
Foley catheter residents without temporary care plan: 1
BIMS score: 14
Inspection Report
Follow-Up
Deficiencies: 3
Jun 18, 2013
Visit Reason
This is a post-certification revisit to verify that previously reported deficiencies have been corrected as of the revisit date.
Findings
The report confirms that deficiencies previously cited under regulations 483.20(d), 483.20(k)(1), 483.25(d), and 483.25(g)(2) have been corrected as of 06/18/2013.
Deficiencies (3)
| Description |
|---|
| Deficiency related to regulation 483.20(d), 483.20(k)(1) |
| Deficiency related to regulation 483.25(d) |
| Deficiency related to regulation 483.25(g)(2) |
Report Facts
Deficiencies corrected: 3
Inspection Report
Follow-Up
Deficiencies: 1
Jun 18, 2013
Visit Reason
This report documents a revisit conducted to verify that previously identified deficiencies have been corrected by the facility.
Findings
The revisit confirmed that the deficiency identified under regulation 28-39-158(a) with ID prefix S0600 was corrected as of the revisit date.
Deficiencies (1)
| Description |
|---|
| Deficiency under regulation 28-39-158(a) previously cited was corrected. |
Inspection Report
Plan of Correction
Deficiencies: 4
May 24, 2013
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 deficiencies related to restorative services plans, catheter care, feeding tube care, and staff credentialing, with corrective actions including staff education, observation, and quality assurance monitoring.
Severity Breakdown
D: 3
C: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Restorative services plans for residents #63 and #77 lacked specific number of repetitions for restorative programs. | D |
| Direct care staff required additional education and skills training on performing catheter care. | D |
| Facility staff needed in-service education on keeping the head of the bed elevated for residents receiving tube feedings and proper care procedures. | D |
| Dietary Manager completed course for credentialing as Certified Dietary Manager and will sit for national exam. | C |
Report Facts
Completion date: Jun 18, 2013
Certification exam date: Oct 1, 2013
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Debra Hartman | Administrator | Submitted the Plan of Correction |
Inspection Report
Follow-Up
Deficiencies: 0
May 20, 2013
Visit Reason
This post-certification revisit was conducted to verify that deficiencies previously reported on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
All previously cited deficiencies identified by regulation or LSC provision numbers were corrected as of the revisit date.
Report Facts
Deficiencies corrected: 14
Inspection Report
Follow-Up
Deficiencies: 1
May 20, 2013
Visit Reason
This revisit report documents the correction of deficiencies previously reported during an earlier survey, verifying that corrective actions were accomplished.
Findings
The report confirms that the previously identified deficiency with ID Prefix S1364 related to regulation 26-40-305 (3) was corrected as of 05/20/2013.
Deficiencies (1)
| Description |
|---|
| Deficiency identified by ID Prefix S1364 related to regulation 26-40-305 (3) |
Inspection Report
Re-Inspection
Census: 59
Deficiencies: 3
May 20, 2013
Visit Reason
The inspection was a Non-Compliance Revisit to assess the facility's correction of previously cited deficiencies related to care planning, catheter care, and tube feeding.
Findings
The facility failed to develop individualized comprehensive restorative nursing care plans for two residents, failed to provide appropriate Foley catheter care for one resident, and failed to provide appropriate care to prevent aspiration for a resident receiving tube feedings. Observations and interviews confirmed lack of specific care plan details and improper care practices.
Severity Breakdown
SS=D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to complete individualized comprehensive restorative nursing care plans for 2 of 3 residents sampled. | SS=D |
| Failed to provide appropriate Foley catheter care for 1 of 3 residents sampled. | SS=D |
| Failed to provide appropriate care to prevent aspiration for 1 resident receiving tube feedings. | SS=D |
Report Facts
Census: 59
Sample size: 11
ROM repetitions: 3
Tube feeding rate: 60
Tube feeding fluid intake: 501
Foley catheter size: 16
Foley catheter balloon size: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff O | Direct care staff interviewed regarding care plan implementation and observed providing care to residents #63 and #77. | |
| Staff P | Direct care staff observed providing range of motion and care to resident #77. | |
| Licensed staff I | Licensed staff assisting with resident transfers and interviewed about care practices for resident #77. | |
| Therapy staff GG | Therapy staff interviewed regarding care plan details and expectations for resident #77. | |
| Licensed nursing staff H | Licensed nurse interviewed about catheter care and tube feeding procedures for resident #63. |
Inspection Report
Plan of Correction
Deficiencies: 15
Apr 19, 2013
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies identified during a prior inspection.
Findings
The Plan of Correction outlines corrective actions for multiple deficiencies including privacy during care, resident preferences for ADL timing, care plan updates, housekeeping and maintenance issues, infection control, and staff education. The facility commits to re-education, monitoring, and compliance audits to address these issues.
Severity Breakdown
D: 10
E: 2
F: 4
Deficiencies (15)
| Description | Severity |
|---|---|
| Failure to ensure privacy while providing cares. | D |
| Failure to honor residents' preferences for timing of blood sugar checks. | D |
| Failure to ensure residents attend appropriate activities and have care plans updated accordingly. | D |
| Housekeeping issues including thick water deposits on faucets, soiled call light cords, and flooring problems. | E |
| Care Area Assessments (CAA) not properly addressing pressure ulcers, catheter use, contractures, antipsychotic medications, and individualized care plans. | E |
| Care plans not reflecting current nutritional information and resident choices. | D |
| Licensed nursing staff not completing dialysis assessment sheets properly. | D |
| Care plans not addressing shaving needs and ADL care. | D |
| Care plans not addressing catheter care properly. | D |
| Restorative services plan not reviewed or revised to fit resident needs. | D |
| Care plans not updated to include Black Box Warning information for medications. | D |
| Food safety issues: open bags of food not labeled and dated in refrigerators and freezers. | F |
| Infection control deficiencies related to C-diff protocols and proper disinfecting of glucometers. | F |
| Facility maintenance issues including cracked sidewalks and unsecured grates. | F |
| Electrical outlet for Hydrocollator replaced with GFCI outlet. | F |
Report Facts
Completion date for corrective actions: Apr 19, 2013
Date of electrical outlet replacement: Mar 18, 2013
Date Dietary Manager sat for national exam: Mar 21, 2013
Date commode provided for resident #100: Mar 19, 2013
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Debra Hartman | Administrator | Administrator named as responsible for monitoring compliance and re-education |
| Shirley Boltz | Contact person for Plan of Correction assistance | |
| Dietary Manager | Dietary Manager | Responsible for re-education of dietary staff and monitoring food labeling compliance |
| Director of Housekeeping | Responsible for rounds to identify housekeeping deficiencies | |
| Director of Maintenance | Responsible for maintenance tasks such as scraping and repainting kitchen ceiling |
Inspection Report
Re-Inspection
Census: 52
Deficiencies: 2
Mar 20, 2013
Visit Reason
The inspection was a Health Resurvey to assess compliance with dietary services and electrical safety regulations.
Findings
The facility failed to have a full-time certified dietary manager on one of four survey days and lacked a policy on dietary manager certification. Additionally, the facility did not provide a ground-fault circuit interrupter (GFI) for the Hydrocollator unit in the therapy room.
Severity Breakdown
F: 1
D: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to have a full-time certified dietary manager on 1 of 4 days of the survey and lacked a policy on certification of a dietary manager. | F |
| Failed to provide a ground-fault circuit interrupter (GFI) for the Hydrocollator unit in the therapy room for 4 of 4 days onsite. | D |
Report Facts
Census: 52
Days without certified dietary manager: 1
Days Hydrocollator lacked GFI: 4
Inspection Report
Plan of Correction
Deficiencies: 2
N052003 POC FF5511
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified in a complaint investigation at the facility.
Findings
The plan addresses deficiencies related to updating resident profiles and care plans for catheters and pressure ulcers, ensuring catheter care documentation on treatment administration records and CNA catheter care flow sheets, and re-educating licensed and certified nursing staff on these requirements.
Complaint Details
This Plan of Correction is related to a complaint investigation identified as Med Leavenworth 072413 Complaint.
Severity Breakdown
D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Resident profile and care plan updates related to catheters and pressure ulcers were incomplete or inaccurate. | D |
| Catheter care information was not consistently included on treatment administration records and CNA catheter care flow sheets. | D |
Report Facts
Complete Date: Aug 16, 2013
Re-education Date: Aug 6, 2013
Certified Nursing Staff Education Date: Aug 2, 2013
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Debra Hartman | Administrator | Submitted the Plan of Correction |
| Shirley Boltz | Contact person for Plan of Correction assistance |
Inspection Report
Plan of Correction
Deficiencies: 8
N052003 POC FQY311
Visit Reason
This document is a Plan of Correction submitted by Medicalodges Leavenworth addressing deficiencies cited in a prior inspection report (2567). It outlines corrective actions to achieve substantial compliance with regulatory requirements.
Findings
The Plan of Correction details multiple corrective actions taken or planned, including repairs to facility infrastructure, staff in-service trainings, care plan updates, and ongoing monitoring through QAPI meetings to ensure compliance.
Deficiencies (8)
| Description |
|---|
| Sink in room shared by four residents repaired and stains removed; toilet repaired; drywall and baseboard repaired in hallways. |
| Coordination of hospice services for resident #9 updated in care plan. |
| Failure to prevent weight loss for resident #34 addressed with nutritional risk interventions. |
| Care plans for residents #25 and #32 reviewed and updated with individualized interventions. |
| Kitchen items cleaned and stored properly; refrigerator access restricted. |
| Staff in-serviced on difference between delayed release and extended release medications. |
| Cement sidewalk and metal hand railing repaired; preventive maintenance program updated. |
| Ice machine taken out of service and cleaned; maintenance and housekeeping processes reviewed. |
Report Facts
Dates for compliance: Oct 6, 2015
Dates for compliance: Oct 12, 2015
Dates for compliance: Oct 15, 2015
Dates for compliance: Oct 20, 2015
Dates for compliance: Oct 28, 2015
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jill Mendenhall | Administrator | Administrator involved in oversight and submission of Plan of Correction |
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