Medicalodges Leavenworth

In the surveyor’s words

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

• Immediate jeopardy, isolatedF602Jul 29, 2025

  The 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. […]

• No harm, potential for more than minimal, widespreadF727Sep 25, 2024

  The 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. Findings included: - The facility's January, February, March, and April 2024 nursing schedule lacked evidence of Registered Nurse coverage for eight consecutive hours a day, on the following dates: 02/10/ 24, 02/11/24, 03/09/24, 03/10/24, and 03/22/24. The facility was unable to provide verifiable, auditable evidence of RN coverage. On 09/24/24 at 02:45 PM Administrative Staff C stated the previous director of nursing was the RN coverage for those dates. […]

• No harm, potential for more than minimal, widespreadF730Sep 25, 2024

  The 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. Findings included: - A review of the facility's staffing list revealed the following CNAs were employed with the facility for more than 12 months: CNA Q, hired on 06/30/22, had no yearly performance evaluations upon request. CNA R, hired on 03/22/19, had no yearly performance evaluations upon request. CNA MM, hired on 02/08/22, had no yearly performance evaluations upon request. […]

• No harm, potential for more than minimal, widespreadF801Sep 25, 2024

  The 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. Findings included: - On 09/23/24 at 08:13 AM Dietary Staff BB stated he had not started the classes to become the Certified Dietary Manager. Dietary Staff BB stated he was trying to get into a dietary manager's class. He stated the Registered Dietician comes every month, and he was able to notify the Registered Dietician by E-Mail, with changes to diets or menus. […]

• No harm, potential for more than minimal, widespreadF882Sep 25, 2024

  The 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. Findings included: - During the entrance conference on 09/23/24 at 07:17 AM, Administrative Staff C stated she was acting as the Infection Preventionist (IP) for the facility. She stated she had been onsite in the facility for 45 days. […]