Westchester Village of Lenexa

Inspectors wroteThe facility identified a census of 26 residents. Based on record review and interviews, the facility failed to ensure agency staff received the required resident rights training. This placed the residents at risk for impaired care and decreased quality of life.

Inspectors wroteThe facility identified a census of 26 residents. The sample included 12 residents with one resident reviewed for dignity. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 19 was appropriately clothed when his bare thigh and leg were showing, and his door was left open. This deficient practice placed R19 at risk for impaired dignity and decreased psychosocial well-being.

Inspectors wroteThe facility identified a census of 26 residents. The sample included 12 residents. Based on record review, interview, and observation, the facility failed to ensure the physician was notified of Resident (R) 2's daily weights that were missed or notified related to weight gain which could lead to fluid overload. The facility further failed to notify R15's physician related to his blood sugar monitoring. This deficient practice placed the residents at risk for further decline and a delay in treatment. [...]

Inspectors wroteThe facility identified a census of 26 residents. The sample included 12 residents, with one resident sampled for discharge. Based on observation, record review, and interview, the facility failed to provide a bed hold with the required information to Resident (R) 7 or to their family representative when R7 was transferred to the hospital. This deficient practice placed R7 at risk for impaired ability to return to the facility or his same room.

Inspectors wroteThe facility identified a census of 26 residents. The sample included 12 residents, with two residents reviewed for treatment and services to prevent and 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 ensure Resident (R) 9's heels were offloading while in bed to prevent pressure ulcers. This placed R9 at increased risk for pressure ulcer development. Findings Included: [...]

Inspectors wroteThe facility identified a census of 26 residents. The sample included 12 residents, with one resident observed for bowel and bladder. Based on observation, record reviews, and interviews, the facility failed to ensure Resident (R) 14's catheter (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid) tubing did not drag on the floor. This deficient practice placed R14 at risk of complications and possible urinary tract infections due to potential urine backflow.

Inspectors wroteThe facility identified a census of 26 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 dosing instructions for as needed Voltaren (topical pain reliever medication) gel and failed to follow a physician order for daily weights to monitor for fluid overload for Resident (R) 2. The facility also failed to follow a physician order for blood sugar monitoring for R15. The facility further failed to ensure R6's anticoagulant (a class of medications sued to prevent the blood from clotting) medication was administered as ordered. These deficient practices placed the residents at risk of unnecessary medication use, side effects, physical complications, and fluid overload.

Inspectors wroteThe facility identified a census of 26 residents. The sample included 12 residents, with five reviewed for immunization status. Based on record reviews and interviews, the facility failed to administer Pneumococcal Conjugate Vaccine (PCV20 - vaccination for bacterial pneumonia infections) vaccination after obtaining a signed consent for Resident (R) 4. This placed the residents at increased risk for complications related to pneumonia.

Inspectors wroteThe facility identified a census of 35. The sample included 12 residents. Based on interview and record review, the facility failed to provide activities on the weekends which reflected the residents' interests, and preferences. This placed the residents at risk for boredom, isolation, and decreased quality of life.

Inspectors wroteThe facility identified a census of 35. The sample included 12 with 12 reviewed for comprehensive care plans. Based on observation, record review and interview, the facility failed to develop a comprehensive care plan related to preventative wound care for Resident (R)22. This deficient practice placed him at risk for complication related to skin injuries and pressure ulcers due to uncommunicated care needs. Findings Included: - The Medical Diagnosis section within R22's Electronic Medical Records (EMR) included diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), major depressive disorder (major mood disorder), restlessness, agitation, reduced mobility, and benign prostatic hyperplasia (BPH-non-cancerous enlargement of the prostate which can lead to interference with urine flow, urinary frequency, and urinary tract infections). [...]

Inspectors wroteThe facility identified a census of 35 residents. The sample included 12 residents with three reviewed for non-pressure related skin conditions. Based on observations, record review, and interviews, the facility failed to implement interventions to identify, treat, and prevent Resident (R)4's traumatic skin injuries. These deficient practices placed R4 at risk for complications related to skin injuries and infections.

Inspectors wroteThe facility identified a census of 35 residents. The sample included 12 residents. Based on observation, record review and interview the facility failed to ensure adequate interventions were in place to address hazards on Resident (R)4's wheelchair and failed to to provide safety provisions, including use of gait belt and foot pedals, for R4. The deficient practice placed R4 at risk for accidents and injuries.

Inspectors wroteThe facility identified a census of 35 residents. The sample included 12 residents with three reviewed for nutrition. Based on observation, record review, and interviews, the facility failed to ensure Resident (R)6 was weighed weekly per his physician's orders. This deficient practice placed R6 at risk for complications related to unintended weight loss.

Inspectors wroteThe facility identified a census of 35 residents. The sample included 12 residents with five residents reviewed for unnecessary medications. Based on observation, record review and interview, the facility failed to ensure the physician indicated an appropriate indication, or a documented physician rationale which included the multiple unsuccessful attempts for nonpharmacological symptom management and risk versus benefits, for the use of an antipsychotic medication (class of medications used to treat psychosis and other mental emotional conditions) for Resident (R) 22, who had a diagnosis of dementia (a progressive mental disorder characterized by failing memory, confusion). This placed R22 at risk for administration of unnecessary psychotropic (alters mood or thought) medications and adverse side effects. Findings Included: [...]

Inspectors wroteThe facility identified a census of 35 residents. The sample included 16 residents which five residents reviewed for immunizations. Based on record review and interviews, the facility failed to obtain pneumococcal (pneumonia infection that inflames air sacs in one or both lungs which may fill with fluid) vaccination consents, declinations, or administration information for Residents (R) 7 and R22. This deficient practice placed residents at increased risk for pneumonia and related complications.

Inspectors wroteThe facility had a census of 28 residents. The sample included 12 residents. Based on observation, record review, and interviews the facility failed to promote care in a manner to maintain and enhance dignity and respect, when staff obtained Resident (R) 23's blood pressure and R7's oxygen saturation at the dining room table, and administered a topical cream to R7's neck at the dining room table, with multiple residents in full view. This created the risk for impaired dignity and psychosocial wellbeing for R23 and R7.

Inspectors wroteThe facility had a census of 28 residents. The sample included 12 residents with one resident reviewed for discharge. Based on interview and record review, the facility failed to complete a discharge summary for Resident (R)32 that included a recapitulation (a concise summary of the resident's stay and course of treatment in the facility) summary of the resident's stay in the facility. This placed R32 at risk for miscommunication or interruptions in the continuum of care after.

Inspectors wroteThe facility had a census of 28 residents. The sample included 12 residents with one reviewed for positioning and mobility. Based on observation, record review, and interview the facility failed to recognize and provide the necessary cares and services to ensure appropriate wheelchair and bed positioning for Resident (R) 10 which placed R10 at increased risk for increased pain and decreased function.

Inspectors wroteThe facility had a census of 28 residents. The sample included 12 residents, with four reviewed for accidents. Based on observation, record review, and interview, the facility failed to follow Resident (R)7's toileting and fall interventions as directed in the plan of care. This placed R7 at increased risk for injuries related to accidents and/or hazards.

Inspectors wroteThe facility had a census of 28 residents. The sample included 12 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)8. This placed R8 at risk for physical decline and complications related to low blood pressure.

Inspectors wroteThe facility had a census of 28 residents. The sample included 12 residents, with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to notify the physician of out of parameter blood pressures for Resident (R)8. This placed R8 at risk for physical decline and complications related to low blood pressure.

Inspectors wroteThe facility had a census of 28 residents. The sample included 12 residents. Based on observation, record review, and interview the facility failed to ensure staff performed appropriate hand hygiene and/or glove usage during perineal care (involves washing the genital and rectal areas of the body or perineal area) for Resident (R) 10. This deficient practice placed R10 at risk for cross-contamination and increased risk for infection.