Medicalodges Great Bend

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure there was sufficient nursing staff to the facility failed to ensure there was a sufficient number of staff as outlined in the Facility Assessment, when the full-time Director of Nursing (DON) also served as the facility's required part-time Infection Preventionist as well performing Minimum Data Set (MDS) duties.

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

Inspectors wroteBased on interviews and record review, the facility failed to conduct a criminal background check as required for one facility employee. The employee was allowed access to residents without knowing if they had been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law., or mistreatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to discard expired stock medication from the 300 and 400 Hall medication cart.

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide accommodation of needs for Resident (R) 35 when staff failed to promptly provide him with access to local channels, which he paid for.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a 14-day stop date or a specified duration with rationale for Resident (R)1's ongoing as needed (PRN) antianxiety (class of medications that calm and relax people) medications.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure nursing staff followed appropriate infection control procedures related to disposal of soiled personal protective equipment, hand hygiene, and catheter care.

Inspectors wroteThe facility failed to provide Resident (R) 1, who was a known wanderer, adequate supervision to prevent R1 from wandering down three long hallways and being pushed four to five feet in the air by another resident, R2, which resulted in an injury fall. R1 sustained a left femoral neck fracture (a serious type of hip fracture, a break in the upper part of the thigh bone just below the ball of the hip joint).

Inspectors wroteThe facility identified a census of 43 residents, with six residents reviewed for abuse and neglect. Based on record review, observation, and interview, the facility failed to ensure six residents, Resident (R) 1, R2, R3, R4, R5, and R6, remained free from verbal and mental abuse when Certified Nurse's Aide (CNA) M exhibited aggressive behavior toward the residents. This failure resulted in R1, R2, R3, R4, R5, and R6 experiencing verbal/mental abuse, which likely caused embarrassment, humiliation, and a potential decreased quality of life using the reasonable person concept related to their psychosocial well-being.

Inspectors wroteThe facility identified a census of 43 residents, with six residents reviewed for abuse and neglect. Based on record review, observation, and interview, the facility failed to report suspected and observed abuse of Residents (R) 1, R2, R3, R4, R5, and R6 when Certified Nurse's Aide (CNA) M exhibited aggressive behavior toward the residents.

Inspectors wroteThe facility identified a census of 38 residents, with four residents reviewed for elopements (when a resident leaves the premises or a specific safe area without authorization and/or necessary supervision). Based on record review, observation, and interview, the facility failed to provide adequate supervision to prevent an elopement for cognitively impaired Resident (R) 1, who the facility identified as a high risk for elopement. On 04/05/24 at approximately 04:18 PM, R1 exited the facility's 200 hall through an unlocked door, which did not alarm. R1 walked approximately the length of a football field over cracked sidewalks, uneven grassy areas, a parking lot full of large potholes, and over several curbs before falling, between two apartment buildings, behind the facility. [...]

Inspectors wroteThe facility had a census of 37 residents. Based on record review and interview, the facility failed to ensure staff completed the required 12-hour in-service education for Certified Nurse Aide (CNA) N and CNA T, who were all employed by the facility for at least one year. This deficient practice placed the residents at risk of decreased quality of care.

Inspectors wroteThe facility identified a census of 37 residents. The sample included 12 residents with five residents sampled for accidents. Based on observation, record review, and interview, the facility failed to ensure an environment free from accident hazards when the facility failed to secure fully pressurized supplemental oxygen cylinders in a safe, locked area, and out of reach of the five cognitively impaired independently mobile residents. The facility additionally failed to ensure interventions were put in place for 22 of Residents (R) 33's 41 falls. This deficient practice placed the residents at risk for preventable accidents, falls, and injuries.

Inspectors wroteThe facility had a census of 37 residents. The sample included 12 residents. Based on observation, interview, and record review the facility failed to ensure a medication error rate of less than five percent. This deficient practice placed Resident (R) 21 at risk for significant medication errors and resulted in a facility medication error rate of 7.69 percent (%) placing all residents who received medication at risk for medication errors.

Inspectors wroteThe facility had a census of 37 residents. The sample included 12 residents. Based on observation, interview, and record review the facility failed to ensure the Consultant Pharmacist (CP) identified and notified the facility and physician of the numerous times staff administered two blood pressure medications to Resident (R) 21 when the physician order indicated the medications should have been held (not administered) in April, May, and June 2024. This deficient practice placed R21 at risk for unintended results from medications.

Inspectors wroteThe facility had a census of 37 residents. The sample included 12 residents with five reviewed for unnecessary drugs. Based on observation, interview, and record review the facility failed to hold Resident (R) 21's blood pressure medication per the physician ordered blood pressure parameters. This deficient practice placed R21 at risk for unnecessary medications and related complications.

Inspectors wroteThe facility identified a census of 42 residents. The sample included three residents reviewed for therapeutic diets (a modification of a regular diet to fit the nutrition needs of a particular person and are modified for nutrients, texture, and/or food allergies or intolerances). Based on observations, record review, and interviews, the facility failed to provide the physician-ordered thickened liquids to Resident (R) 1, who had a history of dysphagia (difficulty swallowing) and aspiration (inhaling liquid or food into the lungs). On 01/07/24, Certified Nurse Aide (CNA) M served R1 thin liquids during breakfast instead of nectar thick liquids (mildly thickened liquids). Licensed Nurse (LN) G observed R1 coughing and choking afterward. LN H suctioned R1 multiple times but R1 continued to sound congested. Staff sent R1 to the emergency room (ER). [...]

Inspectors wroteThe facility identified a census of 42 residents. The sample included three residents with one reviewed for medications. Based on observations, record review, and interview, the facility failed to accurately transcribe and administer antibiotic (medications used to treat bacterial infections) orders for Resident (R) 1 upon her return from the emergency room (ER). This deficient practice placed R1 at risk for ineffective treatment for aspiration pneumonia (an inflammatory condition of the lungs caused by inhaling foreign material or vomit) and unwarranted physical complications.

Inspectors wroteThe facility identified a census of 46 residents with three residents reviewed for elopement (when a cognitively impaired resident leaves the facility without the knowledge or supervision of staff). Based on record review, observation, and interview, the facility failed to identify likely avenues of exit, including windows, and failed to ensure the windows were secured to prevent Resident (R) 1, who was severely cognitively impaired and a high risk for elopement, from exiting the facility through the window. On 12/20/23 at 08:00 PM, Certified Nurse Aide (CNA) M assisted R1 to bed and then began the constant surveillance of R1's room from the nurse's station due to R1's high elopement risk and his multiple attempts to elope. At 09:10 PM CNA N observed R1 outside the front door, knocking over the patio furniture. The temperature outside was approximately 39 degrees Fahrenheit (F). [...]

Inspectors wroteThe facility had a census of 44 residents. The sample included 16 residents with two reviewed for nutrition. Based on observation, record review, and interview, the facility failed to provide weekly weights, failed to act on Registered Dietician (RD) recommendations, failed to monitor supplement and fortified food intake and failed to ensure staff offered fortified food and nutritional supplements to R9, who was at risk for unintended weight loss and had a significant unplanned weight loss of 10.94 percent in six months. The facility further failed to implement RD recommendations, provide and monitor nutritional supplements as ordered and consistently measure weights for R18 who was at risk for weight loss. This deficient practice placed the residents at increased risk for ongoing weight loss and related complications

Inspectors wroteThe facility had a census of 44 residents. The sample included 16 residents. Based on observation, record review and interview the facility staff failed to handle beverages appropriately and clean the plate carts before placing clean dishes on them. This deficient practice placed the 44 residents of the facility at risk for food borne illness.

Inspectors wroteThe facility had a census of 44 residents. The sample included 16 residents with five sampled for immunizations. Based on record review and interview, the facility failed to provide documentation for five sampled residents influenza (a highly contagious viral infection of the respiratory passages causing fever, severe aching, inflammation of the nose and throat, often occurring in epidemics) vaccinations, Resident (R)27, R6, R28, R19, and R24. This placed the residents at increased risk of illness.

Inspectors wroteThe facility had a census of 44 residents. The sample included 16 residents. Based on observation, interview, and record review the facility failed to provide a clean, comfortable, safe environment by not ensuring the kitchen floor tiles remained intact and failed to ensure the ice machine drainage system had a two inch air gap in the line. This deficient practice placed residents at increased risk for illness.

Inspectors wroteThe facility had a census of 44 residents. The sample included 16 residents. Based on observation, record review and interview, the facility failed to identify and report Resident (R)24's missing fentanyl (narcotic medication for pain) patchs to the State Agency (SA) as an allegation of misappropriation. This placed the resident at risk for ongoing abuse and/or misappropriation.

Inspectors wroteThe facility had a census of 44 residents. The sample included 16 residents. Based on observation, interview, and record review, the facility failed to investigate Resident (R) 24's missing fentanyl (narcotic) patches. This placed the resident at risk for ineffective pain relief and unidentified misappropriation.

Inspectors wroteThe facility had a census of 44 residents. The sample included 16 residents. Based on observation, record review, and interview, the facility failed provide a baseline care plan within forty-eight (48) hours of admission for Resident (R) 37 which placed the resident at risk of unmet care needs.

Inspectors wroteThe facility had a census of 44 residents. The sample included 16 residents. Based on observation, record review, and interview, the facility failed to develop a comprehensive plan of care for Resident (R)37 which placed the resident for unmet care needs.

Inspectors wroteThe facility had a census of 44 residents. The sample included 16 residents, with two reviewed for nutrition. Based on observation, record review, and interview, the facility failed to revise the care plan with interventions to prevent weight loss for one sampled resident, Resident (R) 9, who was at risk for unintended weight loss and had a significant weight loss of 10.94% in six months. This placed the resident at increased risk for ongoing weight loss and related complications.

Inspectors wroteThe facility had a census of 44 residents. The sample included 16 residents, with 11 reviewed for accidents. Based on observation, record review, and interview, the facility failed to provide a safe environment and failed to implement resident centered interventions for one sampled resident, Resident (R) 3, who had multiple falls. This placed the resident at risk for further falls and injury.

Inspectors wroteThe facility had a census of 44 residents. The sample included 16 residents, with one resident reviewed for bowel and bladder function. The facility failed to provide Resident (R) 37 with assessment and interventions to prevent further bladder incontinence. This placed R37 at risk for functional decline and impaired dignity.

Inspectors wroteThe facility had a census of 44 residents. The sample included 16 residents, with four reviewed for behaviors. Based on observation, record review, and interview, the facility failed to provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for one sampled resident, Resident (R) 14, who stated he wanted to kill himself twice within a three-month period. This placed the resident at risk for further decline of his emotional and mental-wellbeing.

Inspectors wroteThe facility had a census of 44 residents. The sample included 16 residents. Based on observation, record review, and interview, the facility failed to identify and provide medically-related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being of one sampled resident, Resident R14, who stated he wanted to kill himself twice within a three-month period. This placed the resident at risk for further decline of his emotional and mental-wellbeing. [...]

Inspectors wroteThe facility had a census of 44 residents. The sample included 16 residents, with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility's Consultant Pharmacist (CP) failed to identify and report multiple episodes of blood pressures outside of physician ordered parameter for Resident (R) 14. This placed R14 at risk for physical decline and complications related to low blood pressure.

Inspectors wroteThe facility had a census of 44 residents. The sample included 16 residents, with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to hold amlodipine (a medication for high blood pressure) and olmesartan medoxomil-hctz (a medication for high blood pressure) when systolic blood pressures were out of parameter for one of five sampled residents, Resident (R) 14. This placed R14 at risk for physical decline and complications related to low blood pressure.

Inspectors wroteThe facility had a census of 44 resident. The sample included 16 residents, with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to obtain a stop date for Resident (R) 14's PRN (as needed) diazepam (a sedative used to treat anxiety). and failed to ensure an appropriate diagnosis for R17's Seroquel and Zyprexa (antipsychotic medication).

Inspectors wroteThe facility had a census of 44 residents. The sample included 16 residents with one reviewed for hospice (a type of health care that focused on the terminally ill patient's pain and symptoms and attending to their emotional and spiritual needs at the end of life) services. Based on observation, record review, and interview, the facility failed to ensure a coordinated plan of care, which coordinated care and services provided by the facility with the care and services provided by hospice, was developed and available for Resident (R24. This placed R24 at risk for inappropriate end of life cares.