Deficiencies (last 10 years)
Deficiencies (over 10 years)
11.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
87% worse than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
32
24
16
8
0
Occupancy
Latest occupancy rate
58% occupied
Based on a November 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Complaint Investigation
Census: 38
Deficiencies: 1
Date: Nov 18, 2025
Visit Reason
The inspection was conducted following a complaint investigation triggered by an incident where a cognitively impaired resident (R1) eloped from the facility unsupervised, fell, and sustained a head injury.
Complaint Details
The complaint investigation was substantiated. The resident eloped from the facility on 08/25/25, was found injured approximately one-half mile away, and was hospitalized with an acute subdural hematoma. The facility's failure to prevent elopement placed the resident in immediate jeopardy.
Findings
The facility failed to provide adequate supervision for Resident R1, who was at moderate risk for elopement, resulting in the resident leaving the facility grounds unsupervised, falling, and sustaining a serious head injury. The care plan lacked documentation of elopement risk and interventions to prevent unsupervised outdoor activities.
Deficiencies (1)
F 0689: The facility failed to ensure adequate supervision to prevent a cognitively impaired resident at moderate risk for elopement from leaving the facility unsupervised, resulting in a fall and head injury. The resident's care plan lacked documentation of elopement risk and related interventions.
Report Facts
Resident census: 38
Elopement Risk Assessment score: 10
Elopement Risk Assessment score: 11
Inspection Report
Complaint Investigation
Census: 45
Deficiencies: 1
Date: Jul 16, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding mental abuse of cognitively impaired and dependent residents involving unauthorized photographs taken by staff.
Complaint Details
The complaint investigation substantiated abuse based on photographic evidence and resident incapacity to consent. The facility notified law enforcement and the State Agency, suspended and terminated involved staff, and implemented immediate corrective actions.
Findings
The facility failed to prevent mental abuse when a Hospitality Aide took demeaning photos of residents without consent and shared them with other staff. The investigation substantiated abuse, and immediate corrective actions were implemented to remove immediate jeopardy.
Deficiencies (1)
F 0600: The facility failed to protect residents from mental abuse when a Hospitality Aide took unauthorized photos of residents in compromising positions and shared them with staff. This violated residents' rights and placed them in immediate jeopardy due to fear, humiliation, and privacy violations.
Report Facts
Residents affected: 3
Census: 45
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Hospitality Aide P | Took unauthorized photographs of residents and shared them with staff. | |
| Certified Nurse Aide M | Former employee | Received and forwarded photographs; related to Hospitality Aide P. |
| Certified Medication Aide O | CNA/CMA | Was present in one photograph and asked for photos to be deleted. |
| Administrative Staff A | Administrative Staff | Received photos, notified law enforcement and State Agency, and met with families. |
| Administrative Nurse E | Administrative Nurse | Acknowledged incident and oversaw staff re-education on abuse and cell phone policies. |
| Administrator A | Administrator | Reported staff suspensions and terminations related to the incident. |
Inspection Report
Routine
Census: 49
Deficiencies: 20
Date: Aug 14, 2024
Visit Reason
Routine inspection of Medicalodges Eudora nursing home to assess compliance with healthcare regulations and resident care standards.
Findings
The facility had multiple deficiencies including failure to ensure resident dignity, unmet care needs, improper use of restraints, failure to provide timely transfer notifications, incomplete care plan revisions, inadequate range of motion interventions, insufficient fall prevention measures, nutrition and hydration issues, improper use of side rails, lack of RN coverage, missing yearly staff evaluations, incomplete nurse staffing data submission, infection control lapses, failure to provide pneumococcal vaccination, and inadequate psychotropic medication management.
Deficiencies (20)
F 0550: The facility failed to ensure Resident 4's urinary catheter drainage bag was placed in a privacy bag, risking impaired dignity and psychosocial well-being.
F 0558: The facility failed to ensure Resident 24's call light was within reach, risking unmet care needs.
F 0604: The facility failed to ensure Resident 42 was free of physical restraints when placed in a recliner with elevated footrest, risking impaired mobility and autonomy.
F 0623: The facility failed to provide written notification of transfer to Resident 50 or representative, risking miscommunication and missed healthcare opportunities.
F 0625: The facility failed to notify Resident 50 or representative in writing about bed hold duration during hospital transfer, risking impaired return ability.
F 0657: The facility failed to revise Resident 151's care plan with accurate transfer assistance directions, risking impaired care.
F 0688: The facility failed to provide interventions to maintain Resident 151's range of motion and proper positioning, risking further decline.
F 0689: The facility failed to implement meaningful fall prevention interventions for Resident 8, risking future falls and injuries.
F 0692: The facility failed to provide adequate fluids within reach for Resident 14 and failed to implement weight loss interventions for Resident 24, risking dehydration and malnutrition.
F 0700: The facility failed to complete side rail safety assessments and use alternatives before installing side rails for Resident 24, risking injury.
F 0727: The facility failed to provide Registered Nurse coverage for eight consecutive hours daily on multiple dates, risking inadequate care.
F 0730: The facility failed to complete yearly performance evaluations for five Certified Nurse Aides, risking inadequate care.
F 0732: The facility failed to maintain posted daily nurse staffing data for 18 months and omitted daily census, risking staffing transparency.
F 0756: The facility failed to ensure consultant pharmacist identified and reported non-approved CMS indications for antipsychotic medications for Residents 19, 20, 27, and 35, risking unnecessary medication and adverse effects.
F 0758: The facility failed to implement gradual dose reductions or document contraindications for psychotropic medications for Resident 20, risking unnecessary medication and side effects.
F 0801: The facility failed to employ a full-time certified dietary manager to oversee nutritional services, risking inadequate nutrition.
F 0849: The facility failed to implement clear signage and Enhanced Barrier Precautions for residents requiring transmission-based precautions, risking infectious disease transmission.
F 0883: The facility failed to provide Resident 19 with the pneumococcal conjugate vaccine as consented, risking pneumonia complications.
F 0851: The facility failed to submit accurate registered nurse staffing hours to CMS via Payroll Based Journaling, risking unidentified staffing inadequacies.
F 0947: The facility failed to ensure three of five Certified Nurse Aides completed required 12 hours of in-service education, risking inadequate care.
Report Facts
Resident census: 49
Sample size: 14
Certified Nurse Aides reviewed: 5
RN coverage missing days: 6
Months missing posted staffing data: 2
Inspection Report
Routine
Census: 56
Deficiencies: 22
Date: Nov 8, 2022
Visit Reason
Routine inspection of Medicalodges Eudora nursing home to assess compliance with regulatory requirements and resident care standards.
Findings
The facility had multiple deficiencies including failure to provide foot pedals for a resident's wheelchair, failure to notify family and physician of a skin tear, failure to transmit resident assessments timely, incomplete care plans, inadequate bathing and toileting care, failure to prevent skin breakdown, improper medication management, unsafe medication storage, inadequate respiratory equipment care, infection control lapses, lack of RN coverage, incomplete nursing staffing records, and failure to provide immunization documentation.
Deficiencies (22)
F 0558: The facility failed to provide foot pedals for Resident 31's broda chair to prevent her feet from dragging on the floor, placing her at risk for injury.
F 0580: The facility failed to notify Resident 11's representative and physician about a skin tear on her upper arm, risking delayed treatment.
F 0640: The facility failed to electronically transmit Resident 34's Significant Change MDS within 14 days, risking delayed treatment.
F 0656: The facility failed to revise Resident 50's care plan to include interventions to prevent pressure wounds, risking further skin breakdown.
F 0657: The facility failed to provide individualized care plan interventions for Resident 25's bowel and bladder incontinence, risking complications.
F 0677: The facility failed to ensure bathing was provided for Resident 3 who required extensive assistance, risking skin breakdown.
F 0684: The facility failed to implement preventative skin interventions for Residents 11 and 34, placing them at risk for skin injuries.
F 0686: The facility failed to implement immediate interventions for Resident 50's pressure injury, resulting in worsening and infection.
F 0688: The facility failed to apply Resident 19's splint and brace as ordered, risking further decrease in range of motion.
F 0689: The facility failed to secure chemicals and implement an anti-rollback device on Resident 11's wheelchair, risking accidents.
F 0690: The facility failed to provide individualized toileting programs for Residents 25 and 33 and failed to maintain sanitary catheter care for Resident 34.
F 0695: The facility failed to ensure consistent and hygienic respiratory care for Resident 11, risking respiratory complications.
F 0726: The facility failed to ensure an accurate assessment of Resident 11's skin tear by a licensed nurse, risking delayed wound care.
F 0727: The facility failed to provide Registered Nurse coverage for eight consecutive hours on some days, risking inadequate resident care.
F 0732: The facility failed to retain daily posted nursing staffing data for 18 months as required.
F 0755: The facility failed to ensure Resident 18 received prescribed medication timely, risking delayed treatment.
F 0761: The facility failed to ensure safe storage and handling of medications, leaving medication carts unlocked and unattended.
F 0810: The facility failed to provide a plate guard for Resident 19 at meals, risking loss of independence and psychosocial wellbeing.
F 0812: The facility failed to ensure prepared food on room trays was kept at safe temperatures, risking foodborne illness.
F 0880: The facility failed to ensure staff followed safe infection control practices related to isolation, respiratory equipment, urinary catheters, and PPE.
F 0882: The facility failed to designate a qualified infection preventionist with specialized training, risking inadequate infection control.
F 0883: The facility failed to obtain pneumococcal and influenza vaccination consents or documentation for several residents, risking vaccine-preventable illness.
Report Facts
Resident census: 56
Medication unavailable days: 4
Missing nursing staffing days: 92
Missing nursing coverage days: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse G | Licensed Nurse | Involved in skin tear assessment and medication administration |
| Licensed Nurse H | Licensed Nurse | Provided statements on care plans, medication, and infection control |
| Certified Medication Aide R | Certified Medication Aide | Provided statements on foot pedals, catheter care, and medication cart security |
| Administrative Nurse D | Administrative Nurse | Provided multiple interviews regarding care deficiencies and policies |
| Certified Medication Aide S | Certified Medication Aide | Provided statements on bathing, skin care, and medication administration |
| Dietary Staff BB | Dietary Staff | Provided statements on meal assistive devices and food temperatures |
Inspection Report
Routine
Census: 49
Deficiencies: 10
Date: Apr 29, 2021
Visit Reason
Routine inspection of Medicalodges Eudora nursing home to assess compliance with regulatory requirements related to resident care, environment, grievance resolution, bathing services, pressure ulcer care, catheter care, psychotropic medication use, dietary management, and food safety.
Findings
The facility had multiple deficiencies including failure to maintain a clean environment, unresolved resident grievances, inadequate bathing and personal hygiene care for several residents, incomplete nursing assessments and treatments, insufficient documentation of catheter care and output, lack of behavioral monitoring for psychotropic medication use, absence of a certified dietary manager, and unsafe food storage and preparation practices.
Deficiencies (10)
F 0584: The facility failed to maintain a clean and sanitary environment for residents, including unclean toilets and cluttered resident rooms.
F 0585: The facility failed to make prompt efforts to resolve resident council grievances regarding missed baths/showers over several months.
F 0676: The facility failed to provide bathing services as care planned for multiple residents, resulting in poor hygiene and unclean appearance.
F 0677: The facility failed to provide care and assistance for activities of daily living, including bathing, for residents dependent on staff.
F 0684: The facility failed to provide appropriate treatment and care according to physician orders and resident needs, including skin treatments and nursing assessments.
F 0686: The facility failed to provide appropriate pressure ulcer care and prevent new ulcers by not documenting assessments and repositioning for residents with pressure ulcers.
F 0690: The facility failed to document routine catheter care and urinary output for a resident with an indwelling catheter, risking urinary tract infections.
F 0758: The facility failed to document behavioral monitoring for a resident on psychotropic medications, risking unnecessary medication use.
F 0801: The facility failed to employ a full-time certified dietary manager for 49 residents receiving meals from the facility kitchen.
F 0812: The facility failed to store, prepare, and distribute food in accordance with professional standards, including unclean kitchen areas and expired food items.
Report Facts
Resident census: 49
Sample size: 13
Bathing record missing days: 17
Expired food days: 66
Expired food days: 14
Expired food days: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Verified expectations for bathing, treatment administration, documentation, and acknowledged staffing issues |
| Licensed Nurse H | Licensed Nurse | Verified expectations for bathing, treatment administration, and documentation |
| Certified Nurse Aide O | Certified Nurse Aide | Reported bathing completion challenges and care provided |
| Licensed Nurse G | Licensed Nurse | Reported staffing shortages impacting bathing completion |
| Registered Dietician GG | Registered Dietician | Verified lack of certified dietary manager and kitchen cleanliness issues |
| Administrative Staff A | Administrative Staff | Verified lack of certified dietary manager and kitchen cleanliness issues |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Mar 13, 2017
Visit Reason
This visit was conducted as a post-certification revisit to verify that previously cited deficiencies have been corrected.
Findings
All previously reported deficiencies were corrected as of the revisit date. The report documents completion of corrective actions for multiple regulatory requirements.
Inspection Report
Complaint Investigation
Census: 62
Deficiencies: 4
Date: Feb 13, 2017
Visit Reason
The inspection was conducted as a Health Resurvey and Complaint Investigation covering multiple complaint numbers (#99543, #107596, and #101185).
Complaint Details
The visit was complaint-related, investigating multiple complaints (#99543, #107596, and #101185).
Findings
The facility had medication errors exceeding the allowed rate, failed to provide current pneumococcal vaccine education, stored and prepared food under unsanitary conditions, and did not ensure the designated physician attended Quality Assessment and Assurance meetings as required.
Deficiencies (4)
F 332: The facility had a medication error rate of 8%, failing to ensure two residents were free from medication errors, including failure to reorder and administer medications as prescribed.
F 334: The facility failed to provide residents or their representatives with current education regarding pneumococcal immunizations, using outdated vaccine information sheets.
F 371: The facility failed to prepare, store, distribute, and serve food under sanitary conditions, including improper glove use, uncovered plates, and storage of expired sandwiches.
F 520: The facility failed to ensure the designated physician attended Quality Assessment and Assurance meetings for two quarters in 2016.
Report Facts
Resident census: 62
Medication error rate: 8
Residents observed for medication administration: 13
Residents reviewed for immunizations: 5
Sample size: 17
QAA meeting attendance missing: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff P | Direct Care Staff | Unable to locate medication Glipizide and stated it was unavailable. |
| Staff D | Administrative Nursing Staff | Expected staff to reorder medications timely and was unaware of medication unavailability. |
| Staff H | Licensed Nursing Staff | Acknowledged discrepancy between physician's order and actual medication dosage. |
| Staff I | Licensed Nursing Staff | Stated charge nurses were responsible for entering medication orders. |
| Staff B | Administrative Staff | Confirmed outdated pneumococcal vaccine information was provided to residents. |
| Staff FF | Dietary Staff | Handled food and non-food items without changing gloves. |
| Staff GG | Dietary Staff | Confirmed plates were stored uncovered in upright position. |
| Staff DD | Dietary Staff | Stated expectation to cover plates and acknowledged lack of kitchen policy. |
| Staff EE | Dietary Staff | Stated sandwiches had a 3-day expiration and outdated sandwiches were present. |
| Staff A | Administrative Staff | Stated physician attended QAA meetings quarterly but missed one due to vacation. |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Feb 13, 2017
Visit Reason
The visit was a Health survey conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found the most serious deficiencies to be 'F' level, widespread, constituting no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance based on credible allegation of compliance and evidence of correction.
Deficiencies (1)
The survey found 'F' level deficiencies that were widespread and constituted no actual harm but had potential for more than minimal harm that is not immediate jeopardy.
Inspection Report
Plan of Correction
Deficiencies: 5
Date: Feb 13, 2017
Visit Reason
This document is a Plan of Correction submitted by the facility to address deficiencies cited during a prior survey.
Findings
The plan outlines corrective actions for medication ordering and receiving, updating Vaccine Information Statements (VIS), disposal of expired food, and coordination with the medical director for quality assurance meetings.
Deficiencies (5)
F0000: Facility will develop and implement a system to assure continued compliance with Medicare and Medicaid regulations.
F332-D: Medication was reordered and arrived late; staff will be re-educated on ordering and receiving medications with audits to verify accuracy.
F334-E: All outdated VIS forms have been replaced; audits of admission packets for correct VIS will be conducted monthly.
F371-F: All expired food has been disposed of; staff training on food handling and expiration dates will be conducted with ongoing audits.
F520-F: Previous quality assurance meetings reviewed with medical director; coordination for future QA meetings will continue.
Inspection Report
Life Safety
Deficiencies: 1
Date: Jul 11, 2016
Visit Reason
A Life Safety Code survey was conducted by the State Fire Marshal's Office to determine compliance with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies at the facility to be at an 'F' level, indicating no harm with potential for more than minimal harm, but not immediate jeopardy. A plan of correction was required and remedies including denial of payments and possible termination of provider agreement were recommended if substantial compliance is not achieved.
Deficiencies (1)
The facility was cited for deficiencies at an 'F' level under the Life Safety Code survey, indicating no harm but potential for more than minimal harm without immediate jeopardy.
Report Facts
Days to submit plan of correction: 10
Effective date for denial of payments: Oct 11, 2016
Provider agreement termination date: Jan 11, 2017
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure Certification & Enforcement Manager | Signed the report and responsible for enforcement. |
| Brenda McNorton | Director of Fire Prevention Division | Contact for Informal Dispute Resolution process. |
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Aug 20, 2015
Visit Reason
This is a revisit report completed by a State surveyor to verify that previously reported deficiencies have been corrected and to document the date such corrective action was accomplished.
Findings
The report confirms correction of the previously cited deficiency identified by regulation 28-39-162(a) with correction completed on 2015-08-20. No other deficiencies are listed.
Deficiencies (1)
Regulation 28-39-162(a) deficiency was corrected as of 2015-08-20.
Inspection Report
Follow-Up
Deficiencies: 1
Date: Aug 20, 2015
Visit Reason
This visit was a post-certification revisit to verify correction of previously cited deficiencies from the survey completed on 2015-07-23.
Findings
The revisit confirmed that the previously reported deficiencies, including those under regulation 483.25, were corrected as of 2015-08-20.
Deficiencies (1)
Regulation 483.25 deficiency identified by tag F0309 was corrected by the revisit date of 2015-08-20.
Report Facts
Deficiency correction date: Aug 20, 2015
Previous survey date: Jul 23, 2015
Inspection Report
Re-Inspection
Census: 61
Deficiencies: 1
Date: Jul 23, 2015
Visit Reason
The inspection was a health resurvey to assess compliance with care and service requirements following prior deficiencies.
Findings
The facility failed to complete neurological check assessments for two residents with a history of falls. Documentation gaps and incomplete neuro checks were noted despite policy requiring thorough assessments after falls or suspected head injuries.
Deficiencies (1)
F 309: The facility failed to complete neurological check assessments for two residents with a history of falls, resulting in incomplete documentation and potential risk to resident safety.
Report Facts
Resident census: 61
Sample size: 12
Neurological checks missed: 2
Neurological checks completed: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed nursing staff H | Licensed Nursing Staff | Provided statements regarding neuro checks after resident falls |
| Administrative nursing staff D | Administrative Nursing Staff | Interviewed about neuro check expectations and documentation |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Jul 23, 2015
Visit Reason
A Health survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid.
Findings
The survey found the most serious deficiencies to be an "E" level deficiency, pattern, constituting no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, resulting in a finding of substantial compliance effective August 20, 2015.
Deficiencies (1)
The facility had an "E" level deficiency pattern that constituted no actual harm but had potential for more than minimal harm that was not immediate jeopardy.
Inspection Report
Plan of Correction
Deficiencies: 2
Date: Jul 21, 2015
Visit Reason
This document is a Plan of Correction submitted by Medicalodges Eudora in response to deficiencies cited during a survey ending on July 21, 2015.
Findings
The plan addresses neurological assessments for residents after falls and issues with non-functional call light indicator bulbs in utility rooms, including corrective actions and ongoing monitoring plans.
Deficiencies (2)
F309-D: Residents #72 and #78 will have neurological assessments thoroughly completed for any future fall. Nursing staff will be educated and compliance monitored for all un-witnessed falls.
S1000-E: Non-functional call light indicator bulbs in utility rooms were replaced and faulty wiring repaired. Weekly call system checks will be enhanced with detailed documentation.
Inspection Report
Follow-Up
Deficiencies: 1
Date: Oct 9, 2014
Visit Reason
This visit was a post-certification revisit to verify correction of previously cited deficiencies from the survey completed on 2014-09-09.
Findings
The report confirms that the previously cited deficiency related to regulation 483.25(h) was corrected as of 2014-10-09. No other deficiencies are noted.
Deficiencies (1)
Regulation 483.25(h): Previously cited deficiency was corrected by the revisit date of 2014-10-09.
Report Facts
Deficiency correction date: Oct 9, 2014
Inspection Report
Complaint Investigation
Census: 61
Deficiencies: 1
Date: Sep 9, 2014
Visit Reason
The inspection was conducted as a complaint investigation (#78202) regarding the facility's failure to provide adequate supervision to prevent a cognitively impaired resident from leaving the facility unsupervised.
Complaint Details
The complaint investigation #78202 found the facility failed to prevent resident #1, who had severe cognitive impairment and was at high risk for elopement, from leaving the facility unsupervised due to door alarms being turned off or not checked as required.
Findings
The facility failed to ensure door alarms were consistently activated and monitored, resulting in a cognitively impaired resident leaving the facility unsupervised. Documentation showed multiple missed door alarm checks across several months and a door alarm being turned off at the time of the incident.
Deficiencies (1)
483.25(h) The facility failed to provide adequate supervision and accident hazard prevention, allowing a cognitively impaired resident to leave the facility unsupervised due to door alarms not being consistently activated or checked.
Report Facts
Resident census: 61
BIMS score: 3
Fall risk assessment score: 17
Elopement risk assessment score: 16
Missed door alarm checks: 26
Missed door alarm checks: 14
Missed door alarm checks: 28
Missed door alarm checks: 18
Missed door alarm checks: 27
Missed door alarm checks: 16
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Sep 5, 2014
Visit Reason
This document is a plan of correction submitted by Medicalodges Eudora in response to deficiencies cited during a complaint survey ending on September 5, 2014.
Complaint Details
The plan of correction responds to deficiencies cited during a complaint survey ending on September 5, 2014.
Findings
The plan addresses deficiencies related to the exit door alarm system and elopement risk management. The facility outlines corrective actions including staff education, ongoing monitoring, and reporting to ensure compliance with CMS regulations.
Deficiencies (1)
F323-E: The exit door alarm system was found deficient for resident #1. The facility will check the alarm system every shift and maintain sign-off records reviewed by charge nurses and administrators.
Report Facts
Date of complaint survey end: Sep 5, 2014
Plan of correction completion date: Oct 9, 2014
Staff education completion date: Sep 23, 2014
QA meeting review date: Sep 17, 2014
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Michael Boulton | Administrator | Submitted the plan of correction |
Inspection Report
Re-Inspection
Deficiencies: 3
Date: Jun 25, 2014
Visit Reason
This is a revisit report to verify correction of previously cited deficiencies at the facility.
Findings
The report documents that previously reported deficiencies identified by regulation or Life Safety Code provisions have been corrected as of May 27, 2014.
Deficiencies (3)
Regulation 28-39-158(a): Previously cited deficiency corrected as of 05/27/2014.
Regulation 26-40-302(c)(i)(ii)(iii)(iv)(v)(d)(i)(ii): Previously cited deficiency corrected as of 05/27/2014.
Regulation 26-40-305(3): Previously cited deficiency corrected as of 05/27/2014.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jun 25, 2014
Visit Reason
This is a post-certification revisit to verify that previously cited deficiencies have been corrected as of the revisit date.
Findings
All previously reported deficiencies identified on the CMS-2567 have been corrected by the dates listed, with corrections completed by 05/27/2014.
Report Facts
Deficiency correction dates: 11
Inspection Report
Re-Inspection
Census: 59
Deficiencies: 11
Date: Apr 30, 2014
Visit Reason
The inspection was a Health Resurvey to verify compliance with previously cited deficiencies and assess ongoing regulatory compliance.
Findings
The facility was found deficient in multiple areas including failure to report abuse allegations, failure to timely check nurse aide registry, failure to revise care plans, failure to prevent skin issues and initiate neurological checks after falls, failure to provide necessary care and services, failure to maintain nutritional status, failure to ensure drug regimen free from unnecessary drugs, failure to provide accurate pharmaceutical services, failure to monitor side effects of psychotropic medications, and failure to maintain an effective infection control program.
Deficiencies (11)
F225: The facility failed to report an allegation of abuse to the State Survey Agency for one resident.
F226: The facility failed to timely check the Kansas Nurse Aide Registry prior to allowing a staff member to perform direct care.
F280: The facility failed to revise the care plan to include dietary additions for a cognitively impaired resident.
F309: The facility failed to prevent skin issues and initiate neurological checks after unwitnessed falls for multiple residents.
F314: The facility failed to prevent development of pressure ulcers and provide timely interventions for residents at risk.
F315: The facility failed to assess and provide toileting to meet the needs of incontinent residents and failed to complete bladder assessments.
F325: The facility failed to provide proper diet order and nutritional diet as ordered for a resident with recent weight loss.
F329: The facility failed to monitor side effects of psychotropic medications and complete required assessments for a resident.
F425: The facility failed to accurately transcribe medication orders and failed to obtain all components of an order for medication administration.
F428: The pharmacy consultant failed to recognize and recommend monitoring for side effects of psychotropic medication for a resident.
F441: The facility failed to maintain an effective infection control program, including failure to analyze infection data and sanitize areas frequented by the facility cat.
Report Facts
Resident census: 59
Weight: 140
Weight: 155
Weight: 153
Pressure ulcer size: 2
Pressure ulcer size: 1
Pressure ulcer size: 0.2
Pressure ulcer size: 0.2
Inspection Report
Plan of Correction
Deficiencies: 14
Date: Apr 28, 2014
Visit Reason
This document is a Plan of Correction submitted by Medicalodges Eudora in response to deficiencies cited during a survey ending on April 28, 2014.
Findings
The plan addresses multiple deficiencies including timely reporting of abuse allegations, CNA certification verification, nutritional care planning, neurological assessments after falls, pressure sore prevention, incontinence care, medication order accuracy, drug regimen reviews, infection control, and safety measures related to facility equipment and laundry procedures.
Deficiencies (14)
F225: The facility will continue to investigate and report all allegations of abuse timely. A bruise of unknown origin for resident #40 was reported to the state agency on 4/28/14.
F226: The facility will verify CNA certification through the Nurse Aide Registry prior to all hires. The CNA certification for the cited CNA was obtained on April 23, 2014.
F280: Nutritionally at-risk residents will have care plans updated to reflect dietary changes. Resident #32's care plan and diet card were updated on 4/24/14 per Registered Dietician recommendations.
F309: Residents will receive assessments and care plans to maintain well-being. Neurological assessments will be performed for residents #32 and #71 after un-witnessed falls.
F314: Residents will receive care to prevent and heal pressure sores. Skin condition notes and care plans for residents #40 and #44 were updated in late April 2014.
F315: Residents with bladder incontinence will be assessed and have care plans to prevent UTIs. Residents #40, #44, and #4 had care plans updated accordingly.
F325: Nutritional diets will be provided as ordered. Resident #32's care plan and tray card were updated on 4/24/14 and dietary staff informed.
F329: Residents receiving medications with EPS risk will be assessed every 3 to 6 months. A DISCUS assessment was completed for resident #51 on 4/24/14.
F425: Medication orders will contain all information required for safe administration. Orders for residents #63 and #48 were clarified and re-transcribed to the MAR.
F428: Residents' drug regimens will be reviewed monthly by a licensed pharmacist. Reports of irregularities will be provided to the DON and Medical Director for corrective action.
F441: The facility will maintain an Infection Control Program to prevent disease transmission. Staff education and sanitation practices were implemented including areas frequented by the facility cat.
S0600: The Dietary Director is enrolled in certification classes and expected to complete certification by October 1, 2014. Progress will be monitored monthly by the Administrator.
S1364: The hydrocolator outlet was replaced with a GFCI outlet on 4/22/14. Monthly safety rounds will include outlet evaluations.
S950: Laundry sorting barrels were replaced with lids on 5/7/14. Staff were in-serviced on infection control policies related to linen care.
Report Facts
Deficiencies cited: 13
Dates: Apr 28, 2014
Dates: May 27, 2014
Dates: Apr 24, 2014
Dates: May 26, 2014
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Feb 23, 2013
Visit Reason
This is a revisit inspection to verify that previously reported deficiencies have been corrected.
Findings
The report documents that the deficiency identified under regulation 28-39-158(a) with ID prefix S0600 was corrected as of 02/23/2013.
Deficiencies (1)
Regulation 28-39-158(a) deficiency previously cited was corrected by 02/23/2013.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Feb 23, 2013
Visit Reason
This visit was a post-certification revisit to verify that previously cited deficiencies had been corrected as indicated in the plan of correction.
Findings
The report confirms that all previously cited deficiencies identified by regulation numbers 483.20(d), 483.20(k)(1), 483.25(h), 483.25(l), and 483.60(c) were corrected as of the revisit date.
Report Facts
Deficiencies corrected: 4
Inspection Report
Re-Inspection
Census: 60
Deficiencies: 1
Date: Jan 24, 2013
Visit Reason
The inspection was a Health Resurvey to assess compliance with dietary services regulations.
Findings
The facility failed to have a Certified Dietary Manager (CDM) onsite for all 4 days of the survey despite having a census of 60 residents and one central kitchen. Dietary staff without certification performed dietary manager duties while preparing and serving meals.
Deficiencies (1)
28-39-158(a) Dietary services require a Certified Dietary Manager (CDM) onsite. The facility failed to have a CDM for 4 of 4 days during the survey.
Report Facts
Resident census: 60
Days without CDM onsite: 4
Inspection Report
Plan of Correction
Deficiencies: 5
Date: Jan 22, 2013
Visit Reason
This document is a Plan of Correction submitted by Medicalodges Eudora in response to deficiencies cited during a survey ending on January 22, 2013.
Findings
The facility was cited for deficiencies related to care plan development, fall assessments, environmental hazards, medication monitoring including black box warnings, and staff certification. The Plan of Correction outlines corrective actions with target completion dates to achieve substantial compliance.
Deficiencies (5)
F279: The facility will develop comprehensive care plans for each resident, including hospice care coordination and specific ADL needs related to dressing, toileting, and personal hygiene. These care plans will be reviewed and revised regularly to ensure ongoing compliance.
F323: Fall assessments have been completed for resident #30. Nurses will be educated on fall assessment protocols and assist bars will be replaced to meet safety guidelines preventing head entrapment.
F329: Resident behavior sheets will be revised to specify psychotropic and other medications with targeted behaviors monitored. Medications with black box warnings will be identified on MARs and care plans with ongoing audits.
F428: Monthly pharmacy reviews will identify at-risk residents for black box warnings and notify the DON of irregularities. The pharmacist will complete drug regimen reviews to ensure compliance.
S600: The Dietary Director does not currently have dietary manager certification but is enrolled in a certification class scheduled for October 2013. Support is provided by corporate and contracted dietitians.
Report Facts
Deficiencies cited: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Michael Boulton | Administrator | Submitted the Plan of Correction |
Inspection Report
Follow-Up
Deficiencies: 1
Date: Jul 20, 2012
Visit Reason
This visit was a post-certification revisit to verify correction of previously cited deficiencies.
Findings
The report confirms that the previously reported deficiency under regulation 483.25(h) was corrected as of the revisit date.
Deficiencies (1)
Regulation 483.25(h) deficiency was corrected by the revisit date of 2012-07-20.
Inspection Report
Complaint Investigation
Census: 67
Deficiencies: 1
Date: Jun 20, 2012
Visit Reason
The inspection was conducted as a result of complaint investigation #57449 regarding the facility's failure to provide adequate supervision and assistive devices to prevent falls.
Complaint Details
The citation resulted from complaint investigation #57449 concerning fall prevention failures.
Findings
The facility failed to provide adequate supervision and assistive devices to prevent falls for three sampled residents with histories of falls and cognitive impairments. Specific failures included lack of non-skid strips, call lights not within reach, and malfunctioning or absent bed/chair alarms.
Deficiencies (1)
483.25(h) The facility failed to ensure the resident environment was free of accident hazards and did not provide adequate supervision or assistive devices to prevent falls for three sampled residents.
Report Facts
Resident census: 67
Sample size: 3
Falls: 2
Falls: 2
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Jun 19, 2012
Visit Reason
This document is a Plan of Correction submitted by Medicalodges Eudora in response to deficiencies cited during a complaint investigation conducted on June 19, 2012.
Complaint Details
This Plan of Correction is related to deficiencies cited from a complaint investigation conducted on June 19, 2012. The facility neither confirms nor accepts the survey findings as legitimate but is submitting the plan to comply with CMS regulations.
Findings
The facility identified issues related to fall prevention, including the need for communication improvements, identification of high-risk residents, and updating fall care plans. The plan outlines corrective actions such as applying skid strips, updating frequent flier lists, affixing visual aids, and enhancing staff education and communication.
Deficiencies (1)
F323-D: Skid strips were applied to the area of resident #1's bedside the day of the finding. The facility updated the Frequent Flier list and affixed airplane stickers to resident #2's room picture to identify high-risk residents.
Report Facts
Deficiencies cited: 1
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N023003 POC LKWR11
Visit Reason
This document is a plan of correction related to a prior inspection event identified as LKWR11 for the facility with State ID N023003.
Findings
No specific deficiencies or findings are detailed in this document. It serves as a placeholder or record for the plan of correction submission.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N023003 POC XXCI11
Visit Reason
This document is a Plan of Correction related to a prior inspection event identified as XXCI11 for the facility with State ID N023003.
Findings
No deficiency records or details are provided in this Plan of Correction document.
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