Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Leonardville Nursing Home during CMS and state inspections, most recent first.
A resident with a history of vascular dementia and repeated falls experienced multiple falls due to the facility's failure to implement effective, resident-centered interventions and provide adequate supervision. Despite having a care plan with various interventions, the facility did not ensure the proper functioning of sensor alarms or timely staff response, leading to repeated incidents where the resident attempted to move without assistance. The facility's lack of effective intervention and supervision placed the resident at risk for ongoing falls.
Two residents were prescribed Seroquel without appropriate physician documentation or qualifying diagnoses, violating the facility's Psychotropic Medication Use Policy. Despite recommendations from the Consultant Pharmacist, the necessary documentation was not provided, placing the residents at risk for unnecessary psychotropic medication.
The facility failed to ensure a coordinated hospice care plan for two residents, leading to inadequate end-of-life care. One resident with severe cognitive impairment and another with atherosclerotic heart disease lacked essential hospice information in their care plans, such as contact details, visit frequency, and provided medications and supplies. This deficiency resulted from a lack of adherence to the facility's policy on interdisciplinary coordination with hospice providers.
A facility failed to follow proper infection control practices during urinary catheter care for a resident, increasing the risk of infection. A CMA and CNA entered the resident's room with PPE, but the catheter bag was found on the floor. The CMA provided care, but did not change gloves appropriately, and touched the catheter bag with contaminated gloves. An Administrative Nurse confirmed the protocol was not followed, which requires hand hygiene and prevents the catheter bag from touching the floor.
Failure to Prevent Repeated Falls for a Resident
Penalty
Summary
The facility failed to identify causative factors for falls and implement meaningful, resident-centered interventions, including adequate supervision, to prevent falls for a resident, referred to as R13, who experienced repeated falls over the past year. R13's medical history included vascular dementia, macular degeneration, unsteadiness, repeated falls, age-related cognitive decline, chronic left leg weakness, and an ataxic gait. Despite these conditions, the facility did not adequately assess and adjust interventions to prevent further falls, as evidenced by multiple incidents where R13 fell, often without the sensor alarms functioning properly or staff responding in a timely manner. R13's care plan included various interventions such as the use of a call light, pressure alarm systems, and staff assistance for transfers and toileting. However, these interventions were not consistently effective. The report details numerous instances where R13 fell, often due to the malfunctioning of sensor alarms or the lack of immediate staff response. In several cases, R13 attempted to go to the bathroom or retrieve personal items without assistance, leading to falls. The facility's failure to ensure the proper functioning of sensor alarms and to provide adequate supervision contributed to these repeated incidents. The facility's Fall Prevention Protocol required the development of a plan to improve or maintain the resident's balance and reduce fall risks, with regular evaluations by the leadership team and QAPI committee. Despite this protocol, the facility did not adequately monitor the effectiveness of the interventions or adjust them based on R13's needs and fall history. This lack of effective intervention and supervision placed R13 at risk for ongoing falls and potential injuries.
Inadequate Documentation for Antipsychotic Use
Penalty
Summary
The facility failed to ensure appropriate indications for the use of antipsychotic medications for two residents, leading to a deficiency in medication management. Resident 26, diagnosed with restlessness, agitation, and anxiety disorder, was prescribed Seroquel without a qualifying diagnosis such as schizophrenia, Huntington's disease, or Tourette's syndrome. Despite multiple reviews by the Consultant Pharmacist, the physician did not provide the necessary documentation or rationale for the continued use of Seroquel, placing the resident at risk for unnecessary psychotropic medication. Similarly, Resident 31, diagnosed with dementia, was also prescribed Seroquel without a qualifying diagnosis. The resident's care plan noted agitation and yelling, but the physician's orders lacked a specific diagnosis that justified the use of antipsychotics. The Consultant Pharmacist's recommendations for documentation were not addressed by the physician, and the resident's clinical record did not include the required rationale or risk-benefit analysis for the medication. Observations revealed that both residents were calm and engaged in activities, yet the facility's failure to secure appropriate physician documentation for the use of Seroquel violated their own Psychotropic Medication Use Policy. This policy mandates that a physician's order for a psychotropic drug must include a qualifying diagnosis and a list of behaviors to monitor, which was not adhered to in these cases.
Lack of Coordinated Hospice Care Plan for Residents
Penalty
Summary
The facility failed to ensure a coordinated plan of care for two residents receiving hospice services, which placed them at risk for inadequate end-of-life care. Resident 16, who had severe cognitive impairment and required assistance with daily activities, was admitted to hospice services. However, the care plan lacked essential information such as hospice contact details, visit frequency, and the medications, equipment, and supplies provided by hospice. Observations and interviews with facility staff confirmed the absence of this critical information in the care plan, despite the facility's policy requiring interdisciplinary coordination with hospice providers. Similarly, Resident 11, diagnosed with atherosclerotic heart disease and experiencing frequent moderate pain, was also receiving hospice services. The care plan for this resident did not include specific information about the hospice provider's contact information, the medications, supplies, and equipment they were responsible for, or the frequency of hospice staff visits. Interviews with facility staff revealed that communication with hospice staff occurred through faxes and a hospice notebook, but the care plan lacked the necessary details to ensure proper coordination of care. The facility's policy on End of Life, Palliative, and Hospice Care emphasized the need for an interdisciplinary approach and collaboration with hospice providers to develop an integrated care plan. However, the facility did not adhere to this policy, resulting in a lack of coordination between the nursing home and hospice services for both residents. This deficiency in care planning and communication placed the residents at risk for inadequate end-of-life care.
Infection Control Deficiency in Catheter Care
Penalty
Summary
The facility failed to ensure proper infection control practices during urinary catheter care for Resident 19, placing the resident at increased risk for infections. During an observation, a Certified Medication Aide (CMA) and a Certified Nurse Aide (CNA) entered the resident's room wearing personal protective equipment. The urinary catheter bag was found uncovered and lying directly on the bare floor, which was verified by the CMA as inappropriate. The CMA provided peri-care and bowel incontinence care, removed soiled gloves, washed hands, and then applied new gloves. However, the CMA wiped the resident's bottom again and emptied the catheter bag using the same contaminated gloves. The catheter port was wiped with an alcohol wipe, and the CMA removed her soiled gloves and other PPE before leaving the room. An Administrative Nurse confirmed that gloves should be changed after providing peri-care and before touching the catheter bag and tubing, and that the catheter bag should not touch the floor. The facility's Indwelling Catheter Protocol requires hand hygiene before and after manipulating the catheter site or drainage bag, and prohibits the catheter bag or tubing from touching the floor.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 45 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Leonardville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Wakefield Care And Rehab | 13.3 mi | ★★★★★ | 13 | 0 |
| Clay Center Presbyterian Manor | 13.8 mi | ★★★★★ | 0 | 0 |
| Advena Living Of Clay Center | 14 mi | — | 0 | 0 |
| Stoneybrook Retirement Community | 16.6 mi | ★★★★★ | 9 | 0 |
| Via Christi Village Manhattan, Inc | 17.2 mi | ★★★★★ | 8 | 1 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Leonardville Nursing Home.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.