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Inspection visit

Inspection

MEDICALODGES LEAVENWORTHCMS #17516223 citations on this visit
23 citations recorded

Citations

23 citations recorded*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

  • 0200GeneralS&S Epotential for harm

    Meet other general requirements.

  • 0914GeneralS&S Fpotential for harm

    F914 - Be designed or equipped to assure full visual privacy for each

    Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

  • 0923GeneralS&S Epotential for harm

    F923 - Have adequate outside ventilation by means of windows, or mechanical

    Have proper medical gas storage and administration areas.

  • 0223GeneralS&S Fpotential for harm

    Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.

  • 0231GeneralS&S Epotential for harm

    Provide large enough exits.

  • 0293GeneralS&S Epotential for harm

    Have properly located and lighted "Exit" signs.

  • 0345GeneralS&S Fpotential for harm

    Have approved installation, maintenance and testing program for fire alarm systems.

  • 0353GeneralS&S Fpotential for harm

    Inspect, test, and maintain automatic sprinkler systems.

  • 0511GeneralS&S Epotential for harm

    Have properly installed electrical wiring and gas equipment.

  • 0712GeneralS&S Fpotential for harm

    F712 - Frequency of physician visits

    Have simulated fire drills held at unexpected times.

  • 0686GeneralS&S Dpotential for harm

    F686 - Skin Integrity

    Provide appropriate pressure ulcer care and prevent new ulcers from developing.

  • 0690GeneralS&S Dpotential for harm

    F690 - Incontinence

    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

  • 0695GeneralS&S Dpotential for harm

    F695 - Respiratory care, including tracheostomy care and tracheal suctioning

    Provide safe and appropriate respiratory care for a resident when needed.

  • 0727GeneralS&S Fpotential for harm

    F727 - Except when waived under paragraph (f) or (g) of this section, the

    Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

  • 0730GeneralS&S Fpotential for harm

    F730 - Regular in-service education

    Observe each nurse aide's job performance and give regular training.

  • 0755GeneralS&S Epotential for harm

    F755 - Pharmacy Services

    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

  • 0756GeneralS&S Dpotential for harm

    F756 - Drug Regimen Review

    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

  • 0758GeneralS&S Dpotential for harm

    F758 - Medication Errors

    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

  • 0801GeneralS&S Fpotential for harm

    F801 - Staffing

    Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.

  • 0849GeneralS&S Dpotential for harm

    F849 - Hospice services

    Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.

  • 0880GeneralS&S Epotential for harm

    F880 - Infection Control

    Provide and implement an infection prevention and control program.

  • 0882GeneralS&S Fpotential for harm

    F882 - Infection preventionist

    Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.

  • 0947GeneralS&S Fpotential for harm

    F947 - Training Requirements

    Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

FAQ · About this visit

Common questions about this visit

What happened during the September 25, 2024 survey of MEDICALODGES LEAVENWORTH?

This was a inspection survey of MEDICALODGES LEAVENWORTH on September 25, 2024. The surveyor cited 23 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at MEDICALODGES LEAVENWORTH on September 25, 2024?

Yes, 23 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Meet other general requirements."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

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Next steps

Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.

Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.

Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.