Medicalodges Leavenworth

Inspectors wroteBased on observation, record review, and interviews, the facility failed to provide R1 with written decisions on the grievances he submitted.

Inspectors wroteThe facility identified a census of 37 residents, with three residents reviewed for misappropriation of resident property (a form of Abuse). Based on record review, observations, and interviews, the facility failed to protect one cognitively impaired resident (R1) from misappropriation of funds. On 07/21/25, it was discovered that Administrative Staff C downloaded R1's credit card account information to their cell phone to make purchases for R1. Administrative Staff C later admitted to purchasing items on R1's card account for themselves. This deficient practice placed R1, a cognitively impaired resident, in immediate Jeopardy, causing R1 emotional distress and a monetary loss of approximately $6000.00.

Inspectors wroteThe facility identified a census of 34 residents. Based on observation, record review, and interview, the facility failed to provide Registered Nurse (RN) coverage eight consecutive hours a day, seven days a week. This placed all residents who resided in the facility at risk of lack of assessment and inappropriate care.

Inspectors wroteThe facility had a census of 34 residents. The sample included 12 residents and three Certified Nurse Aides (CNA) were reviewed for performance evaluations and the associated in-service training. Based on record review and interview, the facility failed to ensure three of the three CNA staff reviewed had the required yearly performance evaluations completed. This placed the residents at risk for inadequate care.

Inspectors wroteThe facility identified a census of 34 residents and one kitchen. Based on interview and record review, the facility failed to provide the services of a full-time certified dietary manager for the 34 residents who resided in the facility and received their meals from the kitchen. This placed the residents at risk for inadequate nutrition.

Inspectors wroteThe facility identified a census of 34 residents. Based on record review and interviews, the facility failed to designate a staff member employed by the facility at least part-time, with the required qualification and certification as the Infection Preventionist, who was responsible for the facility's Infection Prevention and Control Program. This deficient practice placed all residents at risk for lack of identification, tracking, trending, and treatment of infections.

Inspectors wroteThe facility had a census of 34 residents. Three Certified Nurse Aides (CNAs) were sampled for required in-service training hours. Based on record review and interview, the facility failed to ensure one of the three CNA staff reviewed had the required 12 hours of in-service education. This placed the residents at risk for decreased quality of life and inadequate care.

Inspectors wroteThe facility identified a census of 34 residents. The sample included 12 residents. The facility identified one medication room and two medication carts, one with scheduled medication and one with narcotics and treatments. Based on observation, record review, and interviews, the facility failed to ensure controlled substances were accounted for and reconciled between shifts. This deficient practice placed the residents at risk for misappropriation and/or diversion of controlled substances.

Inspectors wroteThe facility identified a census of 34 residents. The facility identified seven residents on Enhanced Barrier Precautions (EBP-infection control interventions designed to reduce transmission of resistant organisms which employ targeted gown and glove use during high contact care) and two residents on transmission-based precautions (TBC-safeguards designed to reduce the risk of transmission of microorganisms by direct or indirect contact). Based on record reviews, observations, and interviews, the facility failed to implement signage or indicators within the physical environment to alert staff and visitors of the required EBP. The facility failed to sanitize shared equipment between use. The facility further failed to ensure staff performed adequate hand hygiene, and failed to ensure respiratory equipment was stored in a sanitary manner when not in use. [...]

Inspectors wroteThe facility identified a census of 34 residents. The sample included 12 residents with two residents reviewed for treatment/services to prevent/heal pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, because of pressure, or pressure in combination with shear and/or friction). Based on observation, record review, and interviews, the facility failed to implement pressure-reducing interventions for Resident (R) 16. This placed R16 at an increased risk for pressure ulcer development and worsening of present pressure ulcers.

Inspectors wroteThe facility identified a census of 34 residents. The sample included 12 residents with three residents reviewed for catheter (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid) care. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 26 had an anchor for his suprapubic catheter (urinary bladder catheter inserted through the abdomen into the bladder)on his abdomen per standards of practice to prevent pulling and injury. This deficient practice placed R26 at risk for catheter-related complications.

Inspectors wroteThe facility identified a census of 34 residents. The sample included 12 residents with one resident reviewed for respiratory care. Based on observation, record review, and interviews, the facility failed to ensure Resident(R) 27's continuous positive airway pressure (CPAP- ventilation device that blows a gentle stream of air into the nose to keep the airway open during sleep) mask and nasal cannula was stored in a sanitary manner. This placed R27 at an increased risk for respiratory infection and complications.

Inspectors wroteThe facility identified a census of 34 residents. The sample included 12 residents with five residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to ensure the medication regimen review (MRR) was addressed by the physician for Resident (R) 3 and R26. The facility also failed to ensure the Consultant Pharmacist (CP) identified and recommended a gradual dose reduction (GDR) for R3's psychotropic (alters mood or thought) medications. The facility further failed to ensure the CP identified and reported irregularities for R9's non-Center for Medicaid and Medicare (CMS) approved indication for an antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) medication and lack of physician documentation for ongoing use without a gradual dose reduction (GDR)attempted. [...]

Inspectors wroteThe facility identified a census of 34 residents. The sample included 12 residents with five residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 9 had a Center for Medicare and Medicaid Services (CMS) approved indication for the use of an antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) or the required physician documentation. The facility further failed to ensure a gradual dose reduction (GDR) was attempted or documented as contraindicated by the physician with a supporting rationale for R9 and R3. These deficient practices placed these residents at risk for unnecessary medications and adverse side effects.

Inspectors wroteThe facility identified a census of 34 residents. The sample included 12 residents with three residents reviewed for hospice services. Based on observation, record review, and interviews, the facility failed to ensure collaboration regarding Resident (R) 8's care between the nursing home and the hospice 24 hours a day, seven days a week including documentation of a description of the services, medication, and equipment provided to these residents by hospice. This deficient practice created a risk of missed opportunities for services and delayed physical, mental, and psychosocial needs for R8.

Inspectors wroteThe facility identified a census of 35 residents. The sample included three residents reviewed for abuse and/or neglect. Based on record review, and interview the facility failed report an allegation of abuse to the State Agency (SA) for Resident (R)1 within the required timeframe. This placed R1 at risk for ongoing abuse and/or neglect.

Inspectors wroteThe facility identified a census of 35 residents. The sample included three residents reviewed for abuse and/or neglect. Based on record review, and interview the facility failed to investigate bruising of unknown origin for Resident (R)1. This placed R1 at risk for unidentified and ongoing abuse and/or neglect.

Inspectors wroteThe facility identified a census of 39 residents. The sample include 13 residents. Based on observation, record review, and interviews, the facility failed to ensure the privacy of protected health information (PHI) for 39 residents. This deficient practice placed the residents at risk for decreased psychosocial wellbeing. Findings Included: - On 04/04/23 at 07:10AM an initial walk-through of the facility revealed a treatment cart with three used COVID-19 (highly contagious, potentially life-threatening respiratory virus) test swabs on top of the cart in the main entry area next to the dining hall. A resident census was left unsecured and in full view on top of the treatment cart which revealed the COVID-19 status of all 39 residents in the facility. [...]

Inspectors wroteThe facility identified a census of 39 residents. Based on observation, record review and interview, the facility failed to ensure that there was a registered nurse (RN) on staff for at least eight consecutive hours, seven days a week. This deficiency had the potential for poor quality of care and negative outcomes for the residents.

Inspectors wroteThe facility identified a census of 39. The sample included 13 residents with five residents positive for COVID-19 (highly contagious, potentially life-threatening respiratory virus). Based on observations, record review, and interviews, the facility failed to ensure COVID-19 test swabs were stored properly during and after use, failed to prevent cross-contamination during wound care for R25, and failed to ensure soiled isolation personal protective equipment (PPE- equipment used to protect the wearer from hazardous contaminates and substances) was stored in a way to prevent exposure to other residents and staff. This deficient practice had the risk to spread illness to all residents.

Inspectors wroteThe facility identified a census of 39 residents. The sample include 13 residents. Based on observation, record review, and interviews, the facility failed to provide activities for the residents during weekends. This deficient practice placed 39 residents at risk for decreased psychosocial wellbeing. Findings Included: - A review of the facility's Activity Calendar for January, February, and March of 2023 indicated the weekends followed the same three activities of Free Time, Resident Ran Bingo, and Easy Listening Music. The schedule indicated activities available in T.V. room. On 04/05/23 at 03:33PM, Resident Council members reported the facility did not provide weekend activities. The council reported Resident (R)8 often held a bingo game on weekends, but rarely other interactive events would be available. [...]

Inspectors wroteThe facility had a census of 39 residents. The sample included 13 residents with four residents reviewed for accidents. Based on observation, record review and interview the facility failed to secure hazardous materials out of reach of the residents. The facility additionally failed to protect Resident (R)190 from accessing hazardous materials and medical waste. The facility failed to ensure R4's was left at a safe height to prevent fall related injuries. These deficient practices placed the residents at risk for preventable injuries and accidents. Findings Included: - On 04/04/23 at 07:05AM an initial walk-through of the facility revealed five residents on isolation (R5, R6, R12, R33, and R36). The isolation boxes contain germicidal bleach wipes left unsecured on top of the boxes. [...]

Inspectors wroteThe facility identified a census of 39. The sample included 13 residents with one resident sampled for resident rights/dignity. Based on observation, record review, and interview, the facility failed to ensure that resident rights and dignity were respected by staff when Resident (R) 140 was not provided privacy while he received cares. This deficient practice placed R140 at risk for decreased self-esteem and decreased self-worth.

Inspectors wroteThe facility identified a census of 39 residents. The sample included 13 residents with two reviewed for reasonable accommodation of needs related to assistive devices. Based on observation, record review, and interviews, the facility failed to ensure Resident (R)16's call light was within reach and failed to provide R190 wheelchair foot pedals during transport. This deficient practice placed both residents at risk for preventable accidents and injuries. Findings Included: - The electronic medical record (EMR) for R16 documented diagnoses of major depressive disorder (major mood disorder), cognitive communication deficit, unsteadiness of feet, abnormalities of gait and mobility, and a history of falls. R16's Quarterly Minimum Data Set (MDS) dated [DATE] noted a Brief Interview for Mental Status (BIMS) score of zero indicating severe cognitive impairment. [...]

Inspectors wroteThe facility identified a census of 39 residents with 13 residents included in the sample. The facility identified three residents who discharged from Medicare Part A services. Based on interview and record review the facility failed to issue the CMS (Center for Medicare/Medicaid Services) Notification of Medicare Non-Coverage (NOMNC- the form used to notify Medicare A participants of their rights to appeal and the last covered date of service) form 10123 which contained the required information for Resident (R) 240. This failure placed the resident at risk for decreased autonomy and impaired right to appeal.

Inspectors wroteThe facility identified a census of 39 residents. The sample include 13 residents. Based on observation, record review, and interviews, the facility failed to maintain a safe, homelike environment related for Resident (R) 8. This deficient practice had the potential for decreased psychosocial well-being and impaired safety and comfort for the affected resident. Findings Included: - On 04/04/23 at 10:11AM R8 reported that the floorboard on her wall was damaged, and she had requested to have it replaced multiple times. She stated that part of the floor paneling was falling off the wall. She stated that the facility told her, we'll replace it when you move out. She stated it has been damaged for months, but no one has fixed it. She also stated an outlet cover had been left off her wall. An inspection of the wall verified the entire right side of her back wall had paneling pulled outward. [...]

Inspectors wroteThe facility identified a census of 39 residents. The sample included 13 residents with three residents reviewed for hospitalization. Based on observation, record review and interview, the facility failed to provide written notice of transfer with the required information to Resident (R)24 and/or to their family/durable power of attorney (DPOA- legal document that named a person to make healthcare decisions when the resident was no longer able to) in a practicable amount of time. This deficient practice had the risk of miscommunication between facility and resident/family and possible missed opportunity for healthcare service for R24.

Inspectors wroteThe facility identified a census of 39 residents. The sample included 13 residents with one sampled resident reviewed for baseline care plan. Based on observation, record review and interview, the facility failed to ensure Resident (R)140's care plan addressed a care area for oxygen (O2) therapy/use. This deficient practice placed R140 at risk for unmet care needs and increased respiratory complications and a decline in his well-being.

Inspectors wroteThe facility identified a census of 39 residents. The sample included 13 residents with one sampled resident reviewed for intravenous (IV) antibiotic (a medication used to treat infections) use. Based on observation, record review and interview, the facility failed to ensure staff initiated a care plan area for Resident (R) 36 to direct staff on the care for his IV antibiotic care/use. This deficient practice placed R36 at risk of unmet care needs, increased infection, and adverse side effects related to IV fluid and medication administration.

Inspectors wroteThe facility identified a census of 39 residents. The sample included 13 residents with one resident reviewed for hospice and end of life. Based on observation, record review, and interviews, the facility failed to revise Resident (R) 24's care plan with direction or care for dialysis (procedure using a machine to remove excess water, solutes, and toxins from the blood in people whose kidneys can no longer perform these functions naturally). This deficient practice placed R24 at risk of delayed services or adverse risk of complication related to dialysis.

Inspectors wroteThe facility identified a census of 39 residents. The sample included 13 residents and three closed records reviewed with one for hospitalization. Based on record review, and interviews, the facility failed to document a recapitulation and discharge summary of the facility stay upon discharge from the facility for Resident (R) 39. This deficient practice placed R39 at risk for an interruption in the continuity of care.

Inspectors wroteThe facility identified a census of 39 residents. The sample included 13 residents. Based on observation, record review and interview, the facility failed to follow physician ordered daily weights for Resident (R) 15 who required the use of a diuretic (a medication used for the formation and secretion of urine and reduce excess fluids). This deficient practice placed R15 at risk for excess fluid accumulation and physical complications. Findings Included: [...]

Inspectors wroteThe facility identified a census of 39 residents. The sample included 13 residents with one resident reviewed for pressure injuries. Based on observation, record review, and interviews, the facility failed to ensure staff implemented appropriate infection control practices during wound care for Resident (R) 25, who was on antibiotic (medication used to treat bacterial infections) for a wound infection. This deficient practice placed R25 at risk of wound worsening and complications related to infections.

Inspectors wroteThe facility identified a census of 39 residents. The sample included 13 residents. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 4 and R25 received treatment and services to prevent an avoidable reduction in range of motion (ROM) and/or mobility for their multiple contractures (abnormal permanent fixation of a joint). This deficient practice left R4 and R25 at risk for further decline and decreased ROM or mobility.

Inspectors wroteThe facility identified a census of 39 residents. The sample included 13 residents with one reviewed for bowel and bladder management. Based on observation, record review, and interviews, the facility failed to provide services to improve/maintain Resident (R)9's bladder incontinence. This deficient practice placed the resident at risk for complications related to incontinence. Findings Included: - The electronic medical record (EMR) for R9 documented diagnoses of major depressive disorder (major mood disorder), history of urinary tract infections (UTI), Parkinson's disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness), and dementia (progressive mental disorder characterized by failing memory, confusion). [...]

Inspectors wroteThe facility identified a census of 39 residents. The sample included 13 residents with one sampled resident reviewed for intravenous (IV) medications. Based on observation, record review and interview, the facility failed to ensure Resident (R) 36 received care and services for the provision of parenteral fluids (administration occurring elsewhere in the body than the mouth) consistent with professional standards of practice. The facility failed to ensure R36 had a physician's order for the normal saline (NS-saline water solution) flush to be administered via IV before and after administration of IV medications. This deficient practice placed R36 at risk of infection, and adverse side effects related to IV fluid and medication administration.

Inspectors wroteThe facility identified a census of 39 residents. The sample included 13 residents with two sampled residents reviewed for respiratory care. Based on observation, record review and interview, the facility failed to ensure Resident (R)140 had a physician's order for oxygen (O2) therapy/use. The facility further failed to ensure R140's O2 tubing/nasal cannula (NC- a hollow tube used to supply supplemental O2). This deficient practice placed R140 at risk for increased respiratory complications and infection and a decline in his well-being.

Inspectors wroteThe facility identified a census of 39 residents. The sample included 13 residents with one resident reviewed for hemodialysis (procedure using a machine to remove excess water, solutes, and toxins from the blood in people whose kidneys can no longer perform these functions naturally). Based on observation, record review, and interviews, the facility failed to monitor Resident (R) 24's central venous catheter (central line- a catheter placed in a large vein) for signs of infection, bleeding, and proper dressing in place. This deficient practice placed R24 at risk of potential adverse outcomes and physical complications related to dialysis.

Inspectors wroteThe facility identified a census of 39 residents. The sample included 13 residents with one resident reviewed for dementia (progressive mental disorder characterized by failing memory, confusion) care services. Based on observation, record review, and interviews, the facility failed to provide dementia care and services for Resident (R)190. This deficient practice placed R190 residents at risk for impaired ability to achieve and/or maintain their highest practicable level of physical and emotional wellbeing. Findings Included: - The electronic medical record (EMR) for R190 documented diagnoses of dementia, major depressive disorder (major mood disorder), macular degeneration (progressive deterioration of the retina), glaucoma (abnormal condition of elevated pressure within an eye caused by obstruction to the outflow), and history of falling. [...]

Inspectors wroteThe facility identified a census of 39 residents. The sample included 13 residents with five reviewed for unnecessary medications. Based on record review, interviews, and observations, the facility failed to ensure the Consulting Pharmacist (CP) identified and reported Resident (R)15's insulin (hormone which regulates blood sugar) medication given outside the physician ordered parameters. This deficient practice placed R15 at risk for unnecessary medication and side effects.

Inspectors wroteThe facility identified a census of 39 residents. The sample included 13 residents with five reviewed for unnecessary medications. Based on record review, interviews, and observations, the facility failed to follow the medical provider's parameters related to Resident (R)15's insulin (hormone which regulates blood sugar) medication. This deficient practice placed R15 at risk for unnecessary medication and side effects. Findings Inlcuded: [...]

Inspectors wroteThe facility identified a census of 39 residents. The sample included 13 residents with five reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to provide an acceptable indication, or a documented physician rationale which included the multiple unsuccessful attempts for nonpharmacological symptom management and risk versus benefits for the continued use for use for R15's Seroquel (antipsychotic - class of medications used to treat psychological and emotional conditions medication). This deficient practice placed R15 at risk for unnecessary medications and side effects.

Inspectors wroteThe facility identified a census of 39 residents. The sample included 13 residents with one sampled resident reviewed for hospice services. Based on observation, record review and interview, the facility failed to ensure Resident (R)140 had a hospice plan of care in place and available for facility staff direction on hospice provided care. This deficient practice placed R140 at risk for unmet hospice care/services and a decline in his well-being.

Inspectors wroteThe facility identified a census of 39 residents. The sample included 13 residents with five residents reviewed for influenza (a contagious respiratory illness that infect the nose, throat, and sometimes the lungs) and pneumococcal (a disease that refers to a range of illnesses that affect various parts of the body and are caused by infection) immunizations. Based on record review and interview the facility failed to ensure Resident (R)10, R15, and R16, who consented to receive the pneumococcal vaccine, were administered the vaccination. This deficient practice placed these residents at risk for acquiring, transmitting, or experiencing complications from the pneumococcal disease.

Inspectors wroteThe facility identified a census of 39 residents. The sample include 13 residents. Based on observation, record review, and interviews, the facility failed to provide mail services on Saturdays. Findings Included: - On 04/05/23 at 03:33PM, Resident Council members reported that facility does not provide mail services for the residents on Saturdays. The council reported the mail was stored over the weekend at the east nurse's station and distributed the following Monday. On 04/10/23 at 11:15AM Activities Coordinator (AC) X stated he usually hands the mail out on weekdays (Monday through Friday) but is not in the facility over the weekend. He stated he would receive the mail on Monday to give out to the residents. [...]

Inspectors wroteThe facility had a census of 41 residents. Based on interview and record review, the facility failed to ensure the staff person designated as the Infection Preventionist, who was responsible for the facility's Infection Prevention and Control Program, completed the specialized training in infection prevention and control. Finds included: - On 07/19/21 at 01:18 PM, Administrative Nurse D revealed that she was responsible for the Infection Prevention and Control Program and lacked certification as an Infection Preventionist. Furthermore, she revealed the facility lacked a certified Infection Preventionist. [...]

Inspectors wroteThe facility identified a census of 41 residents. The sample included 16 residents, with five residents sampled for medication review. Based on observation, record review, and interview, the facility failed to ensure the Consultant Pharmacist (CP) identified irregularities (target behaviors being monitored) for four residents of five sampled for medication review: resident (R)16, R20, R32, and R34.

Inspectors wroteThe facility identified a census of 41 residents. The sample included 16 residents, with five residents sampled for medication review. Based on observation, record review, and interview, the facility failed to ensure the Consultant Pharmacist (CP) identified irregularities (target behaviors being monitored) for four residents of five sampled for medication review: resident (R)16, R20, R32, and R34.

Inspectors wroteThe facility identified a census of 41 residents. 30 medication administrations were observed for three residents. Based on observations, interviews, and record reviews, the facility failed to ensure a medication error rate of less than five percent (%), with 12 errors affecting Resident (R) 1, making the medication error rate 40%.

Inspectors wroteThe facility had a census of 41 residents. The sample included 13 residents. Based on observation, record review, and interview the facility failed to record the medication room refrigerator in one of two medication rooms.

Inspectors wroteThe facility identified a census of 41 residents. The facility had one main kitchen. Based of observation and interview, the facility failed to store food (opened food items that were not labeled or dated), and utilize proper personal hygiene practices (e.g., proper hand washing and the appropriate use of gloves), to prevent contamination of food.

Inspectors wroteThe facility had a census of 41 residents. The sample included 16 residents. Based on observation, record review, and interview, the facility failed to ensure a staff member correctly used hand hygiene and infection control standards when passing ice to the resident rooms.

Inspectors wroteThe facility had a census of 41 residents. The sample included 16 residents with five reviewed for immunizations. Based on record review and interview, the facility failed to provide five of five residents (R), R1, R11, R19, R25 and R32, with the current Center for Disease Control and Prevention (CDC) pneumococcal, influenza, and coronavirus immunizations.

Inspectors wroteThe facility had a census of 41 residents. The sample included 16 residents, of which two dependent residents were reviewed for bathing. Based on observation, record review, and interviews the facility failed to provide consistent bathing for Resident(R) 25 and R34, who were dependent on staff for bathing. This placed R25 and R34 at increased risk for poor hygiene and decreased psychosocial wellbeing.

Inspectors wroteThe facility identified a census of 41 residents. The sample included 16 residents, with three residents reviewed for pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). Based on observation, record review, and interviews, the facility failed ensure Prafo (pressure reducing ankle foot orthotic) boots were placed on Resident (R) 1's bilateral lower extremities to prevent pressure ulcers. This placed R1 at increased risk for pressure ulcer development.

Inspectors wroteThe facility had a census of 41 residents. The sample included 16 residents. Based on observation, record review, and interview, the facility failed to maintain activities of daily living (ADL) to prevent decline for Resident (R) 24 when they failed to restorative nurse care. This placed R24 at risk for a decline in range of motion (ROM) and decreased functional ability.

Inspectors wroteThe census was 41. The sample included 16 residents with five residents reviewed for accidents. Based on observation, interview, and record review the facility failed to provide protective oversight and supervision for one of two sampled residents for accidents and/or hazards. Resident (R)6 admitted to the facility for skilled services on 01/25/21 after sustaining injuries in a motor vehicle accident (MVA). The facility failed to have a system in place to evaluate, assess, and identify a plan of care to ensure R6 was safe to leave the facility on multiple occasions and failed to ensure he was safe to operate a motor vehicle. [...]

Inspectors wroteThe facility identified a census of 41 residents. The sample included 16 residents, which three residents reviewed for catheter care. Based on observation, record review, and interviews, the facility failed to provide appropriate treatment for a resident with an indwelling catheter (tube inserted into the bladder to drain urine into a collection bag) when the facility failed to provide catheter care for Resident (R) 20, which placed R20 at risk for catheter related complications.

Inspectors wroteThe facility identified a census of 41 residents. The sample included 16 residents and one resident (R) reviewed for tube feeding (administration of nutritionally balanced liquefied foods or nutrients though a tube). Based on observation, record review, and interviews, the facility failed to ensure R1's head of bed (HOB) remained at 45 degrees to prevent the increased risk of complications of aspiration pneumonia (an inflammatory condition of the lungs caused by inhaling foreign material or vomit).

Inspectors wroteThe facility identified a census of 41 residents. The sample included 16 residents. Based on observation, record review, and interviews, the facility failed ensure Resident (R) 94 was free from medication errors when he did not receive his physician ordered enoxaparin (anticoagulant- class of medications used to prevent the formation of blood clots). This deficient practice placed R94 at risk for increased complications and symptoms related to his development of possible blood clots post-surgery.