Medicalodges Great Bend

In the surveyor’s words

From the most serious findings on record at Medicalodges Great Bend, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Apr 21, 2025

  The 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. […]

• Immediate jeopardy, isolatedF803Feb 6, 2024

  The 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. […]

• Immediate jeopardy, isolatedF689Jan 10, 2024

  The 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. […]

• Immediate jeopardy, isolatedF600Jun 13, 2023

  The facility identified a census of 44 residents with three reviewed for neglect. Based on record review, observation, and interview, the facility failed to ensure Resident (R) 1 remained free from neglect when the facility failed to provide the necessary care and services required by R1 to promote and maintain R1's highest level of health and wellbeing. R1 admitted to the facility on [DATE] with an order for losartan (medications used to lower blood pressure) 100 milligrams (mg) daily for hypertension (high blood pressure). The facility failed to administer the losartan for 12 days, until 04/29/23, when R1's representative noted the omission. On that same day, R1 had a high blood pressure of 244/110 millimeters of mercury (mmHg) (normal blood pressure range 120/80 mmHg) and fell . […]

• Immediate jeopardy, isolatedF726Aug 8, 2022

  The facility identified a census of 43 residents. The sample included two residents with two reviewed for quality of care. Based on record review and interview, the facility failed to ensure licensed nursing staff possessed the skills, and knowledge necessary to detect and respond to changes in a resident's condition. On the morning of [DATE] Certified Medication Aide (CMA) R reported Resident (R)1 had difficulty swallowing his pills and was dry heaving to Licensed Nurse (LN) H. R1's clinical record lacked evidence LN H performed an assessment or reported the situation to R1's physician. Around lunchtime, R1 (identified with severe cognitive impairment), was allowed outside by himself for an unknown amount of time, but not more than ,d+[DATE] minutes. […]