Inspection Reports for
Medicalodges Leavenworth

The complaint investigation substantiated that Administrative Staff C misused the resident's credit card information for personal purchases exceeding $5,987.14 since February 2025, with most charges occurring in July 2025. The resident suffered emotional distress and financial loss. The facility took immediate corrective actions and notified law enforcement. An APS report was filed.

The facility failed to protect a cognitively impaired resident from misappropriation of funds by an administrative staff member who used the resident's credit card for personal purchases totaling approximately $6000. Immediate corrective actions were taken including suspension and termination of the staff member, notification of law enforcement, and resident counseling.

The facility failed to protect a cognitively impaired resident from financial misappropriation resulting in approximately $6000 loss and emotional distress. Immediate corrective actions were implemented including staff termination, account audits, counseling, policy in-service, law enforcement notification, and resident communication.

The complaint investigations involved multiple complaint numbers. The resident was found to have suffered financial exploitation by Administrative Staff C, who used the resident's credit card without consent. The facility suspended and terminated the staff member, notified law enforcement, and filed an Adult Protective Services report. The citation was deemed past noncompliance due to corrective actions taken prior to the survey.

The facility failed to protect a cognitively impaired resident from misappropriation of funds by an administrative staff member who used the resident's credit card for personal purchases, causing emotional distress and financial loss of approximately $6000. Immediate corrective actions were taken including suspension and termination of the staff member, account audits, and staff training.

The plan outlines corrective actions for multiple deficiencies including care plan adherence, catheter security, respiratory equipment storage, RN coverage, staff education, medication management, infection control, and training requirements. The facility commits to ongoing monitoring and education to achieve compliance by 10-31-2024.

The inspection was triggered by a complaint investigation KS00189923.

The facility had multiple deficiencies including failure to implement pressure ulcer prevention interventions, improper catheter care, inadequate respiratory equipment sanitation, lack of RN coverage, missing nurse aide performance reviews and in-service training, medication management issues including failure to reconcile controlled substances and address pharmacist recommendations, failure to ensure appropriate psychotropic medication use and gradual dose reductions, lack of a certified dietary manager, inadequate hospice care collaboration, and deficiencies in infection prevention and control practices.

The facility was found deficient in multiple areas including pressure ulcer care, catheter care, respiratory equipment sanitation, RN coverage, staff training, medication management, dietary management, hospice care collaboration, infection control, and infection preventionist designation. These deficiencies placed residents at risk for harm, inadequate care, and infection.

The facility was found deficient in multiple areas including pressure ulcer care, catheter care, respiratory equipment sanitation, RN coverage, staff training, medication management, dietary management, hospice collaboration, infection control, and infection preventionist designation. These deficiencies placed residents at risk for harm, inadequate care, and infection.

The plan addresses deficiencies related to staff education on reporting abuse, neglect, exploitation, and injuries of unknown origin, as well as conducting investigations regarding these issues. The facility commits to ongoing monitoring and compliance through clinical management and quality assurance processes.

The complaint investigation #KS00182670 focused on allegations of abuse related to bruising on Resident 1's forearms. The facility did not report the allegation timely and failed to conduct an adequate investigation. The bruising was noted at discharge, but no documentation or witness statements were found. The facility acknowledged the failure to report and investigate.

The facility failed to report an allegation of abuse involving bruising of unknown origin on Resident 1's forearms to the State Agency within the required timeframe. Additionally, the facility failed to investigate the bruising, placing R1 at risk for ongoing abuse and neglect.

The complaint involved failure to timely report and investigate bruising of unknown origin on Resident 1. The facility identified a census of 35 residents and reviewed three residents for abuse and/or neglect. The bruising was noted at discharge, but the facility did not investigate or report the allegation to the State Agency within required timeframes.

The facility failed to report an allegation of abuse to the State Agency within the required timeframe and failed to investigate bruising of unknown origin for R1. This placed R1 at risk for ongoing and unidentified abuse and/or neglect.

The plan addresses deficiencies related to the administration and removal of Fentanyl patches by requiring two licensed nurses to perform these tasks, auditing all residents with Fentanyl orders for compliance, 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.

The findings represent the results of complaint investigations #KS00182346 and KS00182353 regarding nursing competency and medication management errors.

The facility failed to ensure licensed nursing staff possessed the necessary skills to competently manage fentanyl patches, including removal of previous patches before applying new ones. Additionally, staff signed narcotic control logs verifying removal and destruction of fentanyl patches without proper visual verification, placing residents at risk for medication errors and diversion.

The investigation was triggered by complaints regarding improper fentanyl patch management, including failure to remove previous patches and improper documentation of patch disposal. The complaint was substantiated with findings of medication errors and procedural lapses.

The facility failed to ensure licensed nursing staff possessed the skills necessary to competently care for residents using 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 medication errors, side effects, and potential diversion of controlled substances.

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.

The facility failed to obtain physician ordered daily weights and notify the physician regarding weight gain 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 appropriate rationale for psychotropic medication use for Resident 15, failed to prevent cross-contamination during wound care, and failed to ensure pneumococcal vaccinations were administered after consent for Residents 10, 15, and 16.

The plan addresses multiple deficiencies related to resident rights, privacy, call light accessibility, mail delivery, discharge notices, record confidentiality, environmental safety, care plan updates, infection control, medication administration, wound care, and staff coverage. The facility outlines corrective actions including staff education, monitoring, audits, and ongoing quality assurance reviews.

The facility was found deficient in multiple areas including failure to ensure resident privacy, inadequate accommodation of resident needs, failure to provide mail services on weekends, lack of proper notification for Medicare non-coverage, breaches in resident privacy, unsafe environment maintenance, failure to provide timely transfer notices, incomplete care plans for oxygen therapy and IV antibiotics, inadequate discharge documentation, lack of weekend activities, failure to follow physician orders for daily weights and medication administration, improper wound care infection control, inadequate restorative care, unsafe environment and supervision, failure to protect residents from hazardous materials, incomplete dementia care, insufficient RN coverage, inadequate psychotropic medication management, lack of hospice care plan, and failure to provide pneumococcal vaccinations.

The inspection included a complaint investigation related to resident rights, privacy, care, and safety concerns.

The facility was found deficient in multiple areas including resident rights/privacy, reasonable accommodations, medication administration, care planning, infection control, staffing, dementia care, hospice services, and immunizations. Several residents were at risk due to these deficiencies.

The complaint investigation #KS00167942 involved allegations of neglect related to Resident 1 who fell out of bed and sustained a left knee fracture. The allegation was unsubstantiated, but the facility did not submit the investigation report to the state agency within the required timeframe.

The facility failed to submit a full investigation report of a neglect allegation involving Resident 1 to the appropriate state agency within the required five working days. The investigation concluded the allegation was unsubstantiated, but the report was delayed due to internal review protocols.

The plan outlines corrective actions for multiple deficiencies related to resident care plans, bathing preferences, pressure ulcer prevention, medication administration, behavioral monitoring, infection control, and immunization documentation. The facility commits to staff education, audits, and ongoing monitoring until compliance is achieved.

The inspection included complaint investigations identified by complaint numbers KS00165206, KS00164912, and KS00165557.

The facility was found deficient in multiple areas including failure to provide consistent bathing and ADL care, failure to prevent pressure ulcers, inadequate restorative nursing care, insufficient supervision and documentation of resident leave, improper catheter care, improper tube feeding positioning, medication regimen review deficiencies, medication errors, improper medication storage, food safety violations, infection control lapses, and failure to document immunization status for several residents.

The facility had multiple deficiencies including failure to provide consistent bathing, pressure ulcer prevention, restorative nursing care, accident prevention, catheter care, proper feeding tube positioning, medication error prevention, behavior monitoring, infection control, medication storage, food safety, and immunization documentation.

The complaint survey was conducted for three complaints. The allegations were not substantiated, and no noncompliance was found overall. However, a specific deficiency was cited related to the accident involving the resident and the Hoyer lift.

The facility failed to ensure one resident was free from accidents and injury when staff failed to provide necessary services as directed by the resident's plan of care. Specifically, a Certified Nurse Aide transferred a resident using a Hoyer lift without the required second staff member, causing the lift to tip and the resident to sustain two lacerations on the crown of his head.

The facility failed to ensure resident R1 was free from accidents and safety hazards when staff did not use two staff members to transfer R1 with a Hoyer lift, resulting in two lacerations on R1's head.

The facility initiated a performance improvement plan addressing behavior monitoring charting for residents receiving certain psychotropic medications. The plan includes monthly pharmacist audits and ongoing staff education to ensure compliance.

The facility failed to adequately document behavior monitoring for residents receiving psychotropic medications, including antipsychotic and antianxiety drugs, across multiple residents. This deficient practice had the potential for unnecessary psychotropic medication administration and possible harmful side effects.

The plan addresses multiple deficiencies including updating diabetic care plans, behavior monitoring, fall risk interventions, oxygen and breathing treatment tubing sanitation, and proper notification of physicians regarding vital signs outside parameters. Staff education and ongoing monitoring are planned to ensure compliance.

The inspection was a Health Resurvey and Complaint Investigation #KS00138878.

The facility failed to develop comprehensive care plans addressing diabetic care needs, failed to implement effective fall prevention interventions for residents with high fall risk, failed to ensure sanitary respiratory care equipment, and failed to adequately monitor and document behaviors related to psychotropic medication use for multiple residents. The facility also failed to notify physicians of blood glucose, blood pressure, and pulse readings outside prescribed parameters.

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.

The plan addresses multiple deficiencies related to resident transfer notifications, hospice services, care plan updates, fall risk management, bowel movement protocols, medication administration (DISCUS), hydration and nutrition, and resident safety systems such as call lights. The facility outlines corrective actions including staff education, audits, and ongoing monitoring through the QAPI committee.

The visit included complaint investigations KS00134297 and KS00129748. Resident complaints about call lights not being answered timely were substantiated by observations and staff interviews.

The facility failed to maintain an operable call light system for one of four days of the review. Observations and interviews revealed that bathroom call lights did not activate audible or visual signals at the nursing station, and residents complained about untimely responses to call lights.

All previously reported deficiencies were corrected as of the revisit date. Each deficiency is identified by regulation number and marked as completed.

The Plan of Correction details multiple corrective actions including care plan revisions, environmental repairs, staff education, audits, and monitoring to address deficiencies related to resident care, documentation, infection control, and facility environment.

The survey found the most serious deficiency 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, and the facility was found to be in substantial compliance based on credible allegation of compliance and evidence of correction.

The facility had multiple deficiencies including failure to provide medically-related social services, maintain safe and orderly environment, complete timely comprehensive assessments, develop comprehensive care plans, update care plans for urinary incontinence, provide ADL assistance as planned, provide range of motion services, ensure proper medication administration and monitoring, obtain immunization consents, maintain sufficient nursing staff, post nurse staffing information, maintain safe food temperatures, and implement infection control precautions.

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 remedies including denial of payments and possible termination of provider agreement were recommended if substantial compliance is not achieved.

The report documents that the previously identified deficiency under regulation 28-39-158(a) was corrected as of the revisit date.

The survey found the most serious deficiencies to be '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.

The inspection was triggered by multiple complaints (#91128, #91050, #86772, #85565, #85002).

The facility failed to maintain a sanitary environment, coordinate hospice care, prevent weight loss, monitor psychotropic medication behaviors, maintain a sanitary kitchen, accurately transcribe medication orders, maintain safe equipment, and hold quarterly QAA meetings with the medical director.

The report confirms that the deficiency identified under regulation 483.25(h) was corrected as of the revisit date. No other deficiencies are listed as outstanding.

The investigation was triggered by complaint numbers KS00078988 and KS00089645 regarding elopement risk and supervision failures.

The facility failed to provide effective interventions to prevent elopement for a cognitively impaired resident who was found outside the building on facility grounds. The facility also failed to monitor the function of the wanderguard bracelet, maintain secure doors and alarms, and include the resident's photo in the elopement book as required by facility policy.

The survey found a 'D' level deficiency indicating no actual harm but 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 effective September 23, 2015.

The plan of correction addresses a complaint related to an incident on July 21, 2015, involving resident elopement risk and door alarm failures. Resident #1 was moved closer to the nurse's station and placed on 15-minute safety checks following the incident.

The facility identified deficiencies in securing exit doors and monitoring door alarms, which led to corrective actions including enhanced door checks, staff training, and installation of an upgraded door alarm system.

The survey found the most serious deficiencies to be an "F" level deficiency, widespread, with no harm but potential for more than minimal harm that is not immediate jeopardy.

The facility plans to update resident care plans, improve grooming and perineal care, ensure proper medication administration documentation, and conduct root cause analysis with ongoing monitoring to achieve substantial compliance.

The report confirms that the deficiency identified under regulation 28-39-158(a) with ID prefix S0600 was corrected as of the revisit date.

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 and was found to be in substantial compliance based on the credible allegation of compliance and the plan.

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 admissions and recommendation for termination of provider agreement were imposed.

The facility failed to provide necessary services to maintain good personal hygiene, failed to provide complete perineal care for dependent residents, failed to ensure safe medication administration and documentation, and failed to maintain an effective quality assurance committee to address identified deficiencies.

The Plan of Correction outlines corrective actions for multiple deficiencies including staff training on abuse and neglect policies, resident dignity, call light accessibility, environmental repairs, care plan accuracy, medication administration, fall investigations, dietary sanitation, and pest control. Substantial compliance is targeted by July 19, 2014.

Complaint investigation #KS00074016 conducted with findings of multiple deficiencies related to abuse policy implementation, dignity, call light accessibility, sanitation, care planning, medication management, safety hazards, and pest control.

The facility failed to implement abuse and neglect policies, maintain dignity and respect for residents, provide accessible call lights, maintain a sanitary environment, develop comprehensive care plans, prevent urinary tract infections, ensure medication safety and effectiveness, maintain a safe environment, and provide effective pest control.

The revisit confirmed that the deficiencies previously reported under regulations 483.20(k)(3)(i) and 483.25(d) were corrected as of the revisit date.

The inspection was triggered by complaint investigations #KS65430 and #KS64575.

The facility failed to provide a temporary care plan for a resident with a Foley catheter and pressure ulcers, and lacked a policy and procedure for temporary care plans. The facility also failed to provide documentation and policy for Foley catheter care, with missing catheter care documentation for two residents and lack of medical justification for catheter use.

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.

The report documents that the deficiency identified under regulation 28-39-158(a) with ID prefix S0600 was corrected as of 06/18/2013.

The plan addresses deficiencies related to restorative services plans, catheter care, feeding tube care, and staff credentialing. The facility outlines corrective actions including staff education, observation, and quality assurance monitoring to achieve compliance.

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 feeding.

The report confirms that the deficiency identified as Reg. # 26-40-305 (3) with ID Prefix S1364 was corrected as of 05/20/2013.

The plan outlines corrective actions for multiple deficiencies including privacy during care, resident preferences for ADL timing, care plan updates, housekeeping cleanliness, pressure ulcer care, dialysis assessments, infection control, and maintenance issues.

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.

This Plan of Correction is related to a complaint investigation identified as Med Leavenworth 072413 Complaint.

The plan addresses deficiencies related to resident profiles, care plans, and catheter care documentation. It outlines corrective actions including staff re-education, review processes, and ongoing quality assurance monitoring to achieve substantial compliance by August 16, 2013.

The Plan of Correction details multiple corrective actions including repairs to facility infrastructure, coordination of hospice services, nutritional risk management, care plan updates, medication transcription error corrections, and staff training. The facility reports substantial compliance or plans to achieve it by specified dates in October 2015.