August Healthcare at Leewood

Inspectors wroteBased on record review, interview, document review, and facility policy review, the facility failed to implement their abuse policy and ensure one resident (Resident (R) 94) of one reviewed for abuse was safe after R94 sustained an injury during activity of daily living (ADL) care by a Certified Nurse Aide (CNA), and the facility did not investigate to rule out that abuse occurred out of a total sample of 33 residents. The facility's failure to ensure residents were free from physical abuse caused or was likely to cause serious injury, harm, impairment, or death to a resident. Cross reference F609 and F610. An Immediate Jeopardy was identified on 04/30/26 and was determined to exist on 03/10/25, in the area of S483.12 Freedom from Abuse, Neglect, and Exploitation at a Scope and Severity (S/S) of a J. [...]

Inspectors wroteBased on interview, record review, and policy review, the facility failed to report an allegation of potential abuse after Resident (R)94 sustained an injury during activity of daily living (ADL) care by a certified nurse aide (CNA) timely to the state survey agency for (SSA) for one of five residents (Resident (R) 94) reviewed for abuse out of 33 sampled residents. This had the potential to affect residents in the facility who were at risk for abuse. Cross reference F607 and F610. Findings Include: Review of R94's admission Record, located under the Profile tab of the electronic medical record (EMR), revealed the resident was admitted to the facility on [DATE] with diagnoses which included altered mental status. Review of facility provided Incident Report for Bruise, dated 03/20/25 at 9:45 PM and written by RN1, revealed, . [...]

Inspectors wroteBased on interview, record review, and policy review, the facility failed to investigate an allegation of potential abuse after one resident (Resident (R) 94) sustained an injury during activity of daily living (ADL) care by a certified nurse aide (CNA) for one of five residents (Resident (R) 94) reviewed for abuse out of 33 sampled residents. This had the potential to affect residents in the facility who were at risk for abuse. Cross reference F607 and F609. Findings Include: Review of R94's admission Record, located under the Profile tab of the electronic medical record (EMR), revealed the resident was admitted to the facility on [DATE] with diagnoses which included altered mental status. [...]

Inspectors wroteBased on observation, staff interview and facility document review, it was determined that the facility staff failed to maintain one of three of the facility dumpsters in a sanitary manner. A trash bag approximately half full of trash was hanging on the outside of the dumpster and approximately twelve pairs of used plastic gloves and numerous pieces of debris were found lying on the ground around and behind the facility's dumpster.

Inspectors wroteBased on staff interview, clinical record review and facility document review, it was determined the facility staff failed to provide evidence that all required information was provided to the hospital staff when five out of 47 residents in the survey sample were transferred to the hospital; Residents #101, #85, #71, #2 and #74.

Inspectors wroteBased on staff interview, clinical record review and facility document review, it was determined the facility staff failed to evidence written documentation to the Resident or RP (responsible party) and ombudsman upon transfer for five of 47 residents in the survey sample were transferred to the hospital; Residents #101, #85, #71, #2 and #74.

Inspectors wroteBased on staff interview, clinical record review and facility document review, it was determined the facility staff failed to provide a notice of bed hold when the resident was transferred to the hospital for four of 47 residents in the survey sample, Residents #101, #85, #71 and #74.

Inspectors wrote5. The facility staff failed to develop a care plan for use of a hand splint for Resident #71. On the most recent MDS (minimum data set), a significant change assessment with an ARD (assessment reference date) of 2/9/2022, the resident was assessed as being severely impaired for making daily decisions. Section G documented Resident #71 as being totally dependent on two or more staff for bed mobility, transfers, dressing and personal hygiene. Section O documented Resident #71 using a splint or brace. On 3/15/2022 at approximately 12:45 p.m., an observation of Resident #71 was made in their room. Resident #71 was observed in bed wearing a hand splint on the right hand. The ADL (activities of daily living) documentation survey report for 3/1/2022-3/31/2022 documented in part, Restorative: Splint- Apply Bilateral upper hand resting splint x 2 hrs a day on at 11am, off at 1pm or as tolerated. [...]

Inspectors wrote3. The facility staff failed to revise the comprehensive care plan for the use of compression stockings and a hand splint for Resident #86. On the most recent MDS (Minimum Data Set), a quarterly assessment with an ARD (Assessment Reference Date) of 2/9/22, Resident #86 was scored as having short term and long term memory problems and being moderately impaired in cognitive skills for daily decision making. The resident was coded as requiring supervision for eating and extensive assistance for all other areas of activities of daily living. A review of the clinical record revealed a physician's order dated 7/26/21 for Apply compression stockings (1) in am (morning) and remove at night. A review of the clinical record revealed a physician's order dated 12/30/21 for Apply right hand splint (2) every morning and remove at bedtime. [...]

Inspectors wroteBased on resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to implement a complete pain management program by implementing non-pharmacological interventions prior to the administration of a prn (as needed) pain medications for one of 47 residents in the survey sample, Residents # 56.

Inspectors wroteBased on staff interview, facility document review and clinical record review, it was determined the facility staff failed to maintain a complete and accurate clinical record for one of 47 residents in the survey sample, Resident #39. For Resident #39, the facility staff failed to document any notes related to a pressure injury from the end of January 2022 until March 2, 2022.

Inspectors wroteBased on observation, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to report injuries of unknown origin to the state agency for one of 47 residents in the survey sample, Resident #107. On 3/9/22, the facility staff observed injuries of unknown origin (bruises) on Resident #107's face and left hand. The facility staff failed to report the injuries of unknown origin to the state agency.

Inspectors wroteBased on observation, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to investigate injuries of unknown origin for one of 47 residents in the survey sample, Resident #107. On 3/9/22, the facility staff observed injuries of unknown origin (bruises) on Resident #107's face and left hand. The facility staff failed to investigate these injuries of unknown origin.

Inspectors wroteBased on observation, resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to ensure a complete and accurate MDS assessment for 2 of 47 residents in the survey sample, Residents #83 and #2.

Inspectors wroteBased on clinical record review and staff interview it was determined that the facility staff failed to evidence completion of a level 1 PASRR (preadmission screening and resident review) for 1 of 47 residents in the survey sample, Resident #30. The facility staff failed to complete a level 1 PASRR for Resident #30 who was admitted to the facility on [DATE].

Inspectors wroteBased on observation, resident interview, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to develop a complete baseline care plan for 1 of 47 residents in the survey sample, Resident #315. The facility staff failed to develop Resident #315's baseline care plan to include the use of an incentive spirometer.

Inspectors wroteBased on observation, clinical record review, staff interview and facility document review, it was determined that the facility staff failed to meet professional standards of practice in providing care and services to one of 47 residents in the survey sample, Resident #71. The facility staff failed to completely transcribe a physician order for Resident #71 to include the type of enteral feeding to be administered.

Inspectors wroteBased on observation, staff interview, facility document review and clinical record review, it was determined the facility staff failed to provide care and services for a pressure injury for two of 47 residents in the survey sample, Residents #39 and #2.

Inspectors wroteBased on observation, staff interview and clinical record review, it was determined that the facility staff failed to implement interventions to prevent injury from a fall for one of 47 residents in the survey sample, Resident # 28. The facility staff failed to place a fall mat on the floor next to Resident # 28's bed when they are were in bed.

Inspectors wroteBased on observation, resident interview, staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to provide respiratory care and services to two of 47 residents in the survey sample, Residents #2 and #315.

Inspectors wroteBased on resident interview, staff interview, facility document review and clinical record review, it was determined the facility staff failed to communicate consistently with the dialysis center for one of 47 residents in the survey sample, Resident #44. For Resident #44, the facility staff failed to evidence consistent communication via the dialysis communication book on multiple dates in 2022.

Inspectors wroteBased on observation, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to administer medication in a sanitary manner for 1 of 6 residents in the Medication Administration observation, Resident #35. The facility nurse administered a medication which had been handled in an unsanitary manner to Resident #35.

Inspectors wroteBased on observation, staff interview, facility documentation review, and clinical record review, the facility staff failed to develop and implement a comprehensive person centered care plan for three Residents (Residents #43, #20, and #59) of the 34 residents in the survey sample. 1. Resident #43 did not have a comprehensive care plan for dementia care. 2. Resident #20 did not have a comprehensive care plan for dementia care. 3. Resident #59's care plan did not describe, nor address, his dementia needs, or behaviors.

Inspectors wrote2. Resident #43 did not receive care and services for treatment of her dementia and was placed on an antipsychotic. Resident #43 was admitted to the facility on [DATE]. Diagnoses included, but not limited to, Dementia, muscular dystrophy and high blood pressure. Resident #43's Minimum Data Set (MDS, an assessment protocol) with an Assessment Reference Date of 9-7-18 coded Resident #43 with severe cognitive impairment. The MDS was completed as a significant change in status assessment as the resident had completed Hospice. The resident required extensive care with all ADL's (activities of daily living such as bed mobility and toileting) of two staff members. The resident was incontinent of bowel and bladder. The resident was coded with no behaviors during the seven day lookback. [...]

Inspectors wroteBased on observations, family interviews, staff interviews, facility documentation review, and clinical record review, the facility staff failed to implement policies and procedures regarding a choking incident and a bruise of unknown origin for 2 residents (Resident #82, #78) in a sample of 34 residents. 1. For Resident #82, the facility staff failed to investigate a choking incident. 2. For Resident #78, the facility staff failed to investigate a bruise of unknown origin.

Inspectors wroteBased on observations, family interviews, staff interviews, facility documentation review, and clinical record review, the facility staff failed to investigate a choking incident and a bruise of unknown origin for 2 residents (Resident #82, #78) in a sample of 34 residents. 1. For Resident #82, the facility staff failed to investigate a choking incident. 2. For Resident #78, the facility staff failed to investigate a bruise of unknown origin.

Inspectors wroteBased on observation, staff interview and clinical record review, the facility staff failed for 1 resident (Resident #82) of 34 residents in the survey sample to review and revise the comprehensive care plan. 1. For Resident #82, the facility did not discontinue the use of adaptive utensils on the comprehensive care plan.

Inspectors wroteBased on staff interview, facility documentation and clinical record review the facility failed for 1 resident (Resident #29) in a survey sample of 34 Residents to provide medications as ordered by physician. For Resident #29 the facility failed to obtain medication ordered by physician or obtain substitute until the medication was available.

Inspectors wroteBased on staff interview, facility documentation and clinical record review the facility failed to ensure that 2 Residents (Resident #4 and #82) in a survey sample of 34 Residents were free from unnecessary medications. 1. For Resident #4, the facility failed to attempt gradual dose reduction of Psychotropic Drug Temazepam for a year. 2. For Resident #82, the facility staff failed to ensure she was free from the psychotropic medication Seroquel which is not indicated for residents with a diagnosis of dementia.

Inspectors wroteBased on observation, staff Interview, and facility Record Review, the facility staff failed to ensure that medications were not in an unlocked area, and available to residents. A wall cabinet on the [NAME] unit was open, unlocked, and could be easily accessed by wandering Residents. The cabinet contained 2 open gallon sized zip lock bags of various medications, on the bottom shelf, closest to the counter top.

Inspectors wroteBased on staff interview, facility documentation and clinical record review the facility failed to ensure that 1 Resident (Resident #55) of 34 residents was provided the therapeutic diet as ordered by physician. For Resident #55 the facility failed to ensure Resident was given the correct amount of fluids on his fluid restricted Renal Diet.

Inspectors wroteBased on on observation, staff interview, facility documentation review and clinical record review, the facility staff failed, for one resident (Resident #6) in the survey sample of 24 residents, to provide a dignified living experience during medication administration. The facility staff applied a pain patch to Resident #6's back, asked her to lean forward, and then used a black marker to write the day, month and year on it.

Inspectors wroteBased on observation, staff interview, facility record review, and clinical record review, the facility staff failed to devise, and implement a comprehensive care plan for the use IV (intravenous) potassium and antibiotics for one Resident (Resident #1) in a survey sample of 24 Residents. For Resident #1, IV antibiotics, fluids, and Potassium were not appropriately care planned, and skin breakdown was care planned inappropriately.

Inspectors wroteBased on observation, staff interview, facility documentation and clinical record review, the facility staff failed to maintain the highest practicable well being for 1 Resident (Resident #1) in the survey sample of 24 residents. For Resident #1, the facility failed to ensure IV (intravenous) medications were administered per physician's orders, and standards of professional practice. The facility staff further failed to obtain an IV access timely, and provide care and services during an acute illness.

Inspectors wroteBased on observation, staff interview, facility documentation and clinical record review, the facility staff failed to provide specialized intravenous antibiotic and potassium infusion nursing care for 1 Resident (Resident #1) in the survey sample of 24 residents. For Resident #1, the facility failed to ensure IV (intravenous) medications were administered per physician's orders, and standards of professional practice. The facility staff further failed to obtain an IV access timely, during an acute illness.

Inspectors wroteBased on staff interview, the facility staff failed to ensure staff were trained in emergency procedures. Licensed Practical Nurse D (LPN D), and Certified Nursing Assistant A (CNA A) could not describe fully what response should be made to fire, disaster, and elopement protocols.