Below 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 Medicalodges Eudora during CMS and state inspections, most recent first.
Failure to supervise a cognitively impaired resident at moderate elopement risk led to an unsupervised exit from the facility grounds. Staff opened the door for the resident to go outside in her electric wheelchair, but she later traveled away from the building without staff awareness and was found by EMS about one-half mile away after hitting a curb, falling, and sustaining a head injury. The resident had impaired cognition, a history of CVA, aphasia, and an elopement risk assessment showing moderate risk, but her care plan did not identify elopement risk or include related interventions.
The facility failed to ensure that a resident was protected from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, due to inadequate protective measures and oversight.
The facility failed to ensure RN coverage for eight consecutive hours a day, seven days a week, as required. A review of nursing schedules for several months in 2024 showed missing RN coverage on specific dates. Administrative staff confirmed the lack of evidence for RN coverage, and the facility did not have a policy in place, putting residents at risk of inadequate care.
The facility did not conduct yearly performance evaluations for five CNAs employed for over 12 months, as revealed by a staffing list review and staff interviews. The responsibility for these evaluations was attributed to the DON, but they were not completed, and no policy was available. This placed residents at risk for inadequate care.
The facility did not employ a full-time certified dietary manager for its 49 residents, risking inadequate nutrition. A dietary staff member was not yet certified, and the RD visited monthly. The previous dietary manager had left, and no policy for the position was provided.
The facility failed to submit accurate RN staffing information through PBJ, lacking RN punch times for several dates. Administrative Staff A admitted the absence of a policy for PBJ reporting, despite following CMS guidelines. This deficiency risked inadequate staffing for 49 residents.
The facility failed to ensure that three CNAs completed the required 12 hours of in-service education over the past year. CNA M did not complete any in-services, while CNAs O and P completed only six hours each. Administrative Nurse D indicated that human resources were responsible for ensuring completion, but the facility lacked a policy on staff training, leading to this deficiency.
The facility failed to ensure that the Consultant Pharmacist identified and reported the need for a physician-documented rationale for non-approved CMS indications for antipsychotic medications for several residents. This deficiency was identified through observations, record reviews, and interviews, revealing a lack of recommendations for physician documentation and gradual dose reductions for antipsychotic medications.
The facility failed to ensure appropriate CMS-approved indications or physician documentation for antipsychotic medications for several residents, including those with Alzheimer's and dementia. Residents received medications without documented attempts at gradual dose reduction or physician rationale for continued use, placing them at risk for unnecessary medication and adverse side effects.
The facility failed to implement proper infection control measures, including posting clear signage for TBP and providing EBP for residents with specific medical conditions. Observations revealed a lack of visible signage and PPE for residents with MRSA, catheters, wounds, and ulcers. Staff interviews indicated a lack of awareness and understanding of EBP requirements, and the facility lacked a policy for enhanced barrier precautions, putting residents at risk for infectious diseases.
A resident with a urinary catheter was observed multiple times without a dignity bag covering the catheter bag, compromising their dignity and psychosocial well-being. Despite the care plan's requirement for a privacy bag, staff failed to ensure its use, and the facility lacked a specific policy for dignity, relying instead on standard practice.
A resident with multiple diagnoses, including Parkinson's disease and severe cognitive impairment, was found to have her call light out of reach, contrary to her care plan. Staff interviews confirmed that call lights should be accessible, but the facility lacked a specific policy on accommodating resident needs.
A resident with cognitive impairments was repeatedly placed in a reclined chair with an elevated footrest, which she could not lower on her own, effectively restraining her movement. Despite her care plan indicating she preferred to walk and should not have her feet elevated, staff failed to adhere to these instructions, resulting in a violation of her rights to be free from physical restraints.
A facility failed to provide a written notice of transfer to a resident or their representative for a facility-initiated transfer. The resident, with a history of falls, stroke, atrial fibrillation, and heart failure, was transferred to a hospital due to a change in vital signs and delusions. The facility relied on phone calls for notification and lacked a policy for written communication, leading to a deficiency in documentation.
A facility failed to provide a bed hold notice to a resident or their representative when the resident was transferred to a hospital. The resident, with diagnoses including falls and heart failure, was discharged to a hospital without a documented bed hold notice. Staff interviews indicated that notifications were typically made by phone, but no policy was in place to ensure bed hold notices were completed, leading to this oversight.
The facility failed to revise care plans for two residents, leading to deficiencies in care. One resident's care plan inaccurately required a Hoyer lift for transfers, while staff were unaware of this requirement. Another resident's care plan lacked necessary interventions after a fall. The facility's policy for updating care plans was not followed, resulting in uncommunicated care needs.
A resident with dementia, COPD, and intervertebral disc degeneration required substantial assistance for ADLs and used a wheelchair. The facility failed to ensure proper interventions for her range of motion (ROM), as her care plan lacked specific directions for positioning. Observations showed improper positioning, with her head slumped or resting on the table and arms dangling. Staff interviews revealed a lack of awareness and specific interventions for repositioning, contributing to the deficiency.
A resident with a history of falls and multiple medical conditions experienced repeated falls due to inadequate interventions at an LTC facility. Despite being identified as a high fall risk, the facility failed to consistently implement effective measures, such as appropriate supervision and environmental adjustments, to prevent further incidents. Staff interviews revealed gaps in communication and intervention strategies, contributing to the resident's ongoing risk.
A facility failed to ensure fluids were within reach for a resident with dementia and hemiplegia, risking dehydration. Another resident with multiple diagnoses experienced significant weight loss due to inconsistent provision of milk and failure to implement a dietitian's supplement recommendation, risking malnutrition.
A facility failed to explore alternative measures before installing side rails for a resident with severe cognitive impairment and multiple medical conditions. The facility did not conduct a comprehensive safety assessment or educate the resident or their representative about the risks of side rail use. Observations showed the resident on a low air loss mattress with raised side rails, and staff were unaware of the need for specific measurements to prevent risks.
A facility failed to implement a proper communication process with a hospice provider for a resident receiving hospice services. The resident's care plan lacked details on hospice-covered equipment, medications, and personal care items. Staff interviews revealed a lack of awareness and communication regarding hospice services, and the facility lacked a policy for collaboration with hospice providers, risking inadequate end-of-life care.
A resident did not receive the PCV20 vaccine despite having a signed consent form and being eligible within the required timeframe. The facility's Infection Preventionist confirmed the oversight, citing potential delays in vaccine supply from the pharmacy. The facility's policy requires offering pneumococcal immunization, but this was not followed for the resident.
The facility failed to maintain daily nurse staffing data for 18 months and did not include the daily census on staffing documentation. Staffing documentation for two months was missing, and the posted sheets lacked the daily census for the last 18 months. The responsibility for posting and including the census was shared among administrative staff, but the facility's policy was not followed.
Failure to Supervise Cognitively Impaired Resident at Moderate Elopement Risk
Penalty
Summary
The facility failed to ensure adequate supervision for a cognitively impaired resident who was at moderate risk for elopement. The resident had diagnoses including hepatic encephalopathy, CVA with residual effects, aphasia, mood disorder symptoms, hemiplegia/hemiparesis, bowel and bladder incontinence, and used an electric wheelchair. Her assessments documented impaired cognition, including BIMS scores ranging from severely to moderately impaired, and an elopement risk assessment on 08/02/25 scored her at moderate risk for elopement. Her care plan addressed wheelchair use, transfers, and fall risk, but did not identify her as an elopement risk or include interventions to prevent her from leaving the facility grounds unsupervised. On 08/25/25, Administrative Staff B opened the facility door and allowed the resident and another resident outside to sit on the patio. Staff told an LPN that the resident was outside in her electric wheelchair. The other resident later went back inside, leaving the resident alone outside. The facility staff were unaware the resident had left the facility until EMS called after responding to a 911 call and finding her on the ground approximately one-half mile from the facility. EMS reported that she had hit a curb in her electric wheelchair, fallen, and hit her head. The resident’s records and interviews showed she did not know why she was in the hospital and did not remember falling. The hospital documented an acute right-sided subdural hematoma and hypoxia after the fall. The facility’s investigation and witness statements documented that the resident had been outside without staff supervision, that staff did not know how she was found away from the facility, and that the resident had traveled away from the building in her electric wheelchair. The report also noted that the area where she was found contained roads, curbing, walkways, traffic patterns, and other environmental hazards.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report documents that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's protective measures and oversight.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to provide Registered Nurse (RN) coverage for eight consecutive hours a day, seven days a week, as required by regulations. This deficiency was identified through a review of the facility's nursing schedules for January, February, March, and April 2024, which lacked evidence of RN coverage on specific dates: January 20 and 21, February 17, March 3 and 16, and April 7. During an interview on August 13, 2024, Administrative Staff A confirmed the inability to provide verifiable, auditable evidence of RN coverage for these dates. Additionally, the facility did not have a policy related to RN coverage, which placed all residents at risk of lack of assessment and inappropriate care.
Failure to Conduct Yearly CNA Performance Evaluations
Penalty
Summary
The facility failed to conduct yearly performance evaluations for five Certified Nurse Aides (CNAs) who had been employed for more than 12 months. This deficiency was identified during a review of the facility's staffing list and confirmed through interviews with administrative staff. The CNAs in question were hired on various dates ranging from 2013 to 2023, yet none had received the required evaluations. Administrative Staff A indicated that the Director of Nursing was responsible for these evaluations, while Administrative Nurse D admitted to not having performed them. Additionally, the facility was unable to provide a policy related to yearly performance evaluations. This oversight placed residents at risk for inadequate care.
Failure to Employ Full-Time Certified Dietary Manager
Penalty
Summary
The facility failed to employ a full-time certified dietary manager for its 49 residents, which placed them at risk for inadequate nutrition. Dietary Staff BB, who had been with the facility for only a few days, had completed the necessary classes but had not yet scheduled his certification exam. The Registered Dietician visited the facility monthly, and staff could contact the RD with any concerns. Administrative Staff A confirmed that the facility's certified dietary manager had taken a different position and no longer worked in the kitchen. Additionally, the facility did not provide a policy for the dietary manager position, contributing to the deficiency in nutritional oversight and management.
Inaccurate RN Staffing Information Submission
Penalty
Summary
The facility failed to submit accurate staffing information to the federal regulatory agency through Payroll Based Journaling (PBJ) by not providing registered nurse (RN) coverage hours for specific dates. The facility identified a census of 49 residents and was unable to provide RN punch times for several dates in early 2024. Administrative Staff A acknowledged the inability to provide these punch times and stated that the facility did not have a policy regarding PBJ reporting, although they followed CMS guidelines for payroll reporting. The absence of accurate RN coverage hours placed the residents at risk for unidentified and ongoing inadequate staffing.
Inadequate In-Service Training for CNAs
Penalty
Summary
The facility failed to ensure that three out of five Certified Nurse Aides (CNAs) reviewed had completed the required 12 hours of in-service education over the past 12 months. Specifically, CNA M, who was hired on June 13, 2013, had not completed any of the required in-services in the past year. CNA O, hired on March 15, 2023, and CNA P, hired on April 18, 2022, each completed only six hours of the required yearly in-services. This deficiency was identified through a review of the facility's in-service records and confirmed during an interview with Administrative Nurse D, who stated that human resources were responsible for ensuring the completion of these in-services. However, the facility was unable to provide a policy related to staff training, which contributed to the deficiency. This lack of compliance placed residents at risk for decreased quality of life and/or inadequate care.
Failure to Ensure Proper Documentation for Antipsychotic Medication Use
Penalty
Summary
The facility failed to ensure that the Consultant Pharmacist (CP) identified and reported the need for a physician-documented rationale for non-approved CMS indications for the use of antipsychotic medications for several residents, including R35, R20, R19, and R27. This deficiency was identified through observations, record reviews, and interviews. The CP did not provide recommendations for physician documentation for the rationale for the continued use of antipsychotic medications, which are not approved by CMS for the conditions they were prescribed for. For Resident 35, the electronic medical record documented the use of multiple medications, including antipsychotics, without a gradual dose reduction or a completed Monthly Medication Review (MMR) during the observation period. The facility lacked evidence of CP recommendations for physician documentation for the rationale for the continued use of the antipsychotic medication Abilify. Similarly, Resident 20's records showed the use of antipsychotic medication Risperdal for anxiety without a documented rationale or gradual dose reduction, and the facility was unable to provide a physician-documented rationale for the continued use of psychotropic medications without GDRs. Resident 19's records indicated the use of Seroquel for psychotic disorder with hallucinations without a CMS-approved indication for use. Resident 27, who was on hospice services, received Seroquel for anxious behavior related to major depressive disorder and anxiety, but the facility failed to document a recommendation for a CMS-approved indication for its use. The facility was unable to provide a policy related to the process of CP reporting irregularities, which contributed to the failure to ensure proper monitoring and documentation of antipsychotic medication use.
Deficiency in Psychotropic Medication Management
Penalty
Summary
The facility failed to ensure that several residents had an appropriate CMS-approved indication or the required physician documentation for the use of antipsychotic medications. This deficiency was identified through observations, record reviews, and interviews. Specifically, residents were found to be receiving antipsychotic medications without documented attempts at gradual dose reduction (GDR) or without documentation that GDR was contraindicated. Additionally, there was a lack of physician-documented rationale for the continued use of these medications, placing residents at risk for unnecessary medication administration and potential adverse side effects. Resident 27, who had diagnoses of Alzheimer's disease, dementia, and major depressive disorder, was receiving Seroquel without an appropriate indication listed in the order. Despite being on hospice and having severely impaired cognition, there was no documented attempt at GDR, nor was there a documented physician rationale for the continued use of the medication. Similarly, Resident 19, with diagnoses including dementia and psychotic disorder, was receiving Seroquel for psychotic disorder with hallucinations, but no GDR had been attempted, and the required physician documentation was lacking. Resident 20, diagnosed with Alzheimer's disease and anxiety, was receiving Risperdal for anxiety without a CMS-approved indication or physician documentation. The facility also failed to attempt or document a GDR for this resident. Resident 35, with diagnoses of dementia and mood disorder, was receiving multiple psychotropic medications, including Abilify, without a documented rationale for their continued use or attempts at GDR. The facility's failure to ensure appropriate documentation and medication management placed these residents at risk for unnecessary medications and adverse side effects.
Failure to Implement Infection Control Measures
Penalty
Summary
The facility failed to adequately implement infection prevention and control measures, specifically in the areas of posting clear signage for transmission-based precautions (TBP) and implementing Enhanced Barrier Precautions (EBP) for residents requiring them. During an initial walkthrough, it was observed that a bin containing personal protective equipment (PPE) was placed outside a resident's room without visible signage indicating the necessary precautions. The sign for Droplet Precautions was obscured by a box of gloves, making it unreadable. This resident had Methicillin-resistant Staphylococcus aureus (MRSA) and a gastrostomy tube, indicating a need for clear TBP signage. Additionally, several other residents with conditions such as urinary catheters, wounds, and diabetic ulcers did not have appropriate EBP signage or PPE available outside their rooms. Interviews with facility staff revealed a lack of awareness and understanding regarding the need for signage and PPE for residents requiring EBP. A licensed nurse stated that it was the responsibility of the infection prevention nurse to inform staff about EBP requirements, but there was no evidence of this communication occurring. An administrative nurse expressed a misunderstanding of the guidelines, believing that EBP was only necessary for wounds with bacterial growth, excluding residents with catheters or internal feedings. The facility did not have an enhanced barrier precautions policy in place, contributing to the failure to implement necessary infection control measures, thereby placing residents at risk for infectious diseases.
Failure to Maintain Resident Dignity with Catheter Privacy
Penalty
Summary
The facility failed to ensure that a resident's urinary catheter drainage bag was placed in a privacy bag, which compromised the resident's dignity and psychosocial well-being. The resident, identified as R4, had a medical history that included obstructive and reflux uropathy, muscle weakness, epilepsy, transient ischemic attack, depressive disorder, anxiety, and dysplasia. R4's care plan required the use of a dignity bag to cover the catheter bag when attached to his walker, but observations on multiple occasions revealed that the catheter bag was not covered, exposing the contents to peers and staff. On several occasions, R4 was observed without a dignity bag covering his catheter bag while interacting with peers, such as sitting at a breakfast table and playing Yahtzee in the commons area. Staff interviews confirmed that nursing staff were responsible for ensuring the catheter bag was covered, yet this was not consistently done. The facility did not provide a specific policy for dignity but relied on the standard of practice, which was not adhered to in this case, leading to the deficiency.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to ensure that a resident's call light was within reach, which is a deficiency in accommodating the needs and preferences of residents. The resident, identified as R24, had multiple diagnoses including Parkinson's disease, depression, tardive dyskinesia, schizophrenia, muscle weakness, and dysphagia. The resident's care plan indicated a need for a pancake call light to be placed beside her on the bed due to her risk for falls and dependency on staff for all activities of daily living. However, during observations, the call light was found clipped to the privacy curtain at the bottom of the bed and draped over the resident's lower legs, making it inaccessible. Interviews with facility staff, including a licensed nurse and a certified nurse aide, confirmed that call lights should always be within residents' reach. Despite this standard practice, the facility did not provide a specific policy on the accommodation of needs. The failure to place the call light within reach left the resident at risk for unmet care needs, as she was unable to call for staff assistance when needed.
Failure to Prevent Use of Physical Restraints on a Resident
Penalty
Summary
The facility failed to ensure that a resident, identified as R42, was free from physical restraints. R42, who has a diagnosis of [NAME]-[NAME] syndrome, cognitive-communication deficit, and aphasia, was observed multiple times in a reclined chair with the footrest elevated, which she was unable to lower on her own. This positioning impeded her freedom of movement and mobility, effectively acting as a physical restraint. The resident's care plan specifically noted that she preferred to walk around and sit when she wanted, and that her feet should not be elevated when seated in the living room. Despite the care plan instructions, staff members, including a Certified Medication Aide and a Licensed Nurse, were either unaware of or did not adhere to these guidelines. The Certified Medication Aide admitted to not knowing if R42 liked her feet elevated and acknowledged that R42 could not get out of the recliner without significant effort when the footrest was up. The Licensed Nurse confirmed that R42 liked to walk around and should not have her feet elevated, as it would prevent her from getting up, thus constituting a restraint. The facility's restraint policy emphasizes residents' rights to be free from physical restraints used for discipline or convenience, which was not upheld in this case.
Failure to Provide Written Transfer Notification
Penalty
Summary
The facility failed to provide a written notice of transfer to a resident or their representative for a facility-initiated transfer. The resident, identified as R50, had a medical history that included falls, cerebral infarction, atrial fibrillation, and heart failure. The resident's care plan indicated an intention to discharge home after therapy services. However, the resident experienced a change in vital signs with distress and delusions, leading to an unplanned discharge to a short-term acute hospital. Despite this significant event, the facility did not document or provide evidence of a written notification of the transfer to the resident or their representative. The facility's process for notifying family members of transfers was informal, relying on phone calls rather than formal written communication. A Licensed Nurse (LN) confirmed that she typically called family members to notify them of hospital transfers and was unaware of any requirement to send formal written notifications. Additionally, the facility lacked a policy regarding written notification of transfers or discharges, contributing to the deficiency in communication and documentation for the resident's transfer.
Failure to Provide Bed Hold Notice for Hospitalized Resident
Penalty
Summary
The facility failed to provide a bed hold notice to Resident 50 or their representative when the resident was transferred to a hospital. This deficiency was identified during a review of the facility's practices, which included observations, record reviews, and interviews. Resident 50 had diagnoses of falls, cerebral infarction, atrial fibrillation, and heart failure. The resident's electronic medical record documented an unplanned discharge to a short-term acute hospital with a return not anticipated. Despite this, there was no documentation of a bed hold notice being provided, and the facility was unable to produce evidence of such a notice upon request. Interviews with facility staff revealed that the usual practice was to notify family members by phone when a resident was sent to the hospital, and a bed hold was typically completed at that time unless it was an emergency. However, in this case, the bed hold notice was not completed. The facility also lacked a policy regarding bed hold notifications, which contributed to the oversight. This failure placed Resident 50 at risk for impaired ability to return to the facility or the same room.
Failure to Revise Care Plans for Safe Transfers and Post-Fall Interventions
Penalty
Summary
The facility failed to revise the care plans for two residents, R151 and R8, which led to a deficiency in providing appropriate care. R151's care plan inaccurately documented the need for a Hoyer lift for transfers, despite the resident being able to perform sit-to-stand transfers with the assistance of two staff members. This discrepancy was not communicated to the staff, as evidenced by the Certified Medication Aide (CMA) and Licensed Nurse (LN) who were unaware of the Hoyer lift requirement. The care plan had not been updated to reflect the resident's current transfer needs, which were being addressed through physical therapy to improve leg strength. Additionally, the facility did not revise R8's care plan with necessary interventions following a fall, which could have impacted the resident's care. The facility's policy required the care plan to be an active document reflecting the resident's needs, with the MDS coordinator and interdisciplinary team responsible for reviewing and updating it. However, this process was not followed, resulting in uncommunicated care needs and potential risks for the residents involved.
Failure to Implement ROM Interventions for Resident
Penalty
Summary
The facility failed to ensure that Resident 151 had appropriate interventions in place to prevent further decline in range of motion (ROM) and mobility. Resident 151, who had diagnoses of dementia, chronic obstructive pulmonary disease (COPD), and intervertebral disc degeneration, required substantial to maximal staff assistance for activities of daily living (ADLs) and used a wheelchair for mobility. Despite the documented need for total assistance with transfers and positioning, the care plan lacked specific directions for staff to ensure proper positioning of the resident's upper body, head, and arms to prevent further decline in ROM. Observations revealed that Resident 151 was often positioned improperly, with her head slumped forward or resting on the table, and her arms dangling to the sides of her wheelchair. These observations were made on multiple occasions, indicating a consistent lack of appropriate intervention by the staff. Interviews with staff members, including a Certified Medication Aide and a Licensed Nurse, revealed a lack of awareness and specific interventions for repositioning the resident, particularly at the dining table. The facility's Restorative Program Policy & Procedure emphasized the importance of ongoing assessment and interventions to maintain residents' functional abilities. However, the absence of a restorative nurse aide and the lack of specific staff training and direction contributed to the deficiency. The facility's failure to implement and follow through with necessary interventions placed Resident 151 at risk for further decline in ROM and functionality.
Failure to Implement Effective Fall Interventions for a Resident
Penalty
Summary
The facility failed to implement meaningful interventions for a resident, identified as R8, after multiple falls, placing the resident at risk for future falls and possible injuries. R8's medical history included hemiparesis, transient ischemic attack, cerebral infarction, dementia, unsteadiness, muscle weakness, cognitive-communication deficit, repeated falls, impulse disorder, orthostatic hypotension, depressive disorder, and anxiety. The resident's care plan included various interventions such as monitoring orthostatic blood pressure, medication adjustments, and placing the resident in visible areas to staff. However, these interventions were not effectively preventing falls. R8 experienced several falls, as documented in the facility's records, with incidents occurring in different locations such as the dining room, hallway, and near the resident's recliner. Despite being identified as a high fall risk, the interventions following each fall were inconsistent and often inadequate. For instance, after a fall on 06/25/24, no new intervention was noted, and after another fall on 08/03/24, the intervention was limited to covering skin tears with gauze and kerlix. The facility's policy required a review of each fall to determine the root cause and implement appropriate interventions, but this was not consistently followed. Interviews with staff members revealed that while they were aware of R8's high fall risk, the interventions were not always appropriate or effectively communicated. For example, Geri-sleeves were used as a fall intervention, which staff later acknowledged was not suitable. Additionally, the facility's fall management policy required regular assessments and reviews, but the implementation of these measures was lacking, contributing to the ongoing risk of falls for R8.
Deficiencies in Nutrition and Hydration Management
Penalty
Summary
The facility failed to ensure that fluids were within reach for Resident 14, who had diagnoses of dementia, left-sided hemiplegia, and seizures. Despite being able to communicate her needs and having a care plan indicating she could eat independently, observations showed that her water cup was repeatedly placed out of her reach. On multiple occasions, staff had to be called to reposition the table and water within her reach. Interviews with staff confirmed that fluids should have been accessible to Resident 14, yet the facility lacked a policy related to hydration, placing her at risk for dehydration. Resident 24, diagnosed with Parkinson's disease, depression, tardive dyskinesia, schizophrenia, muscle weakness, and dysphagia, experienced a significant weight loss without a physician-prescribed weight loss regimen. The resident was dependent on staff for all activities of daily living, including eating. Despite a care plan that included a fortified food diet and milk with all meals, observations revealed that milk was not consistently provided. Additionally, the facility failed to implement the Registered Dietitian's recommendation to change and increase the resident's supplement, which was crucial to addressing the weight loss. The facility's failure to provide necessary interventions for Resident 24's weight loss and to ensure Resident 14's fluids were within reach highlights deficiencies in care. The lack of communication and adherence to dietary orders, as well as the absence of a hydration policy, contributed to these deficiencies, placing both residents at risk for adverse health outcomes.
Failure to Assess and Educate on Side Rail Use
Penalty
Summary
The facility failed to attempt alternative measures before installing side rails for a resident, identified as R24, and did not complete a comprehensive side rail safety assessment. R24's medical history included Parkinson's disease, depression, tardive dyskinesia, schizophrenia, muscle weakness, and dysphagia. The resident was documented as having severely impaired cognition and was dependent on staff for all activities of daily living. Despite these conditions, the facility did not document any assessment of the risks versus benefits of using side rails, nor did they provide education to the resident or their representative about the associated risks. Observations revealed that R24 was using a low air loss mattress with side rails raised on both sides of the bed. Interviews with facility staff indicated a lack of awareness regarding the need for specific measurements when assessing side rails with a low air loss mattress. The facility did not have a policy for side rail use and failed to measure potential gaps that could pose a risk. This oversight placed R24 at risk of injury due to unidentified hazards associated with the use of side rails.
Deficient Communication with Hospice Provider
Penalty
Summary
The facility failed to ensure a proper communication process was in place between the facility and the hospice provider for a resident receiving hospice services. The resident, who had diagnoses including Alzheimer's disease, anxiety, aphasia, muscle weakness, and depressive disorder, was admitted to hospice services with a life expectancy of less than six months. The facility's care plan for the resident documented that hospice services were being provided, but it lacked details on the equipment, medications, and personal care items covered by hospice. Additionally, the hospice communication book did not include a hospice care plan, a list of medications covered, or a signed physician order with the admitting diagnosis. Interviews with facility staff revealed a lack of awareness and communication regarding the hospice services provided to the resident. A Certified Medication Aide and a Licensed Nurse indicated that the hospice provider was responsible for providing necessary information, but the Administrative Nurse was unaware of the missing documentation in the hospice communication book. The facility also lacked a policy related to collaboration with hospice providers, which contributed to the risk of missed or delayed services and inadequate end-of-life care for the resident.
Failure to Administer Pneumococcal Vaccine
Penalty
Summary
The facility failed to administer the Pneumococcal Conjugate Vaccine (PCV20) to Resident 19, despite having obtained a signed consent form for the vaccination. The resident's Electronic Medical Record indicated eligibility and the required timeframe for receiving the PCV20 vaccination. However, the clinical record lacked evidence of the vaccine being administered. Administrative Nurse D, the facility's Infection Preventionist, confirmed the presence of a signed consent but could not find documentation of the vaccine being given. She mentioned that the facility sometimes waits for the pharmacy to supply the vaccine, and in this case, the resident was overlooked or missed. The facility's policy, which aligns with CDC guidelines, mandates offering pneumococcal immunization to residents and staff, but this was not adhered to in the case of Resident 19.
Failure to Maintain Daily Nurse Staffing Data and Census
Penalty
Summary
The facility failed to maintain the required daily nurse staffing data for 18 months and did not include the daily census on the staffing documentation. During a review of posted staffing from January 1, 2023, to August 15, 2024, it was found that the facility could not provide staffing documentation for May 2024 and June 2023. Additionally, the posted staffing sheets lacked the daily census for the residents within the facility for the last 18 months. Interviews revealed that the previous business office manager was responsible for ensuring the daily nursing hours were posted, while the director of nursing was ultimately responsible for including the facility census. Administrative Nurse D confirmed her responsibility for posting the daily nursing hours and including the required information. The facility's BIPA Nurse Staff Posting policy, revised in December 2019, required posting staffing data each shift for direct care and licensed nurses, including the census at the beginning of each shift to track necessary staffing.
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Illustrative
What surveyors actually found near you
We read the 463 citations issued within 25 miles in the last 12 months — including the 9 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Eudora
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hillside Village Of De Soto Rehabilitation And Nur | 7.2 mi | ★★★★★ | 7 | 0 |
| Lawrence Memorial Hospital Snf | 8.5 mi | ★★★★★ | 0 | 0 |
| Lawrence Presbyterian Manor | 9.8 mi | ★★★★★ | 13 | 0 |
| Pioneer Ridge Retirement Community | 11.3 mi | ★★★★★ | 26 | 0 |
| Tonganoxie Terrace | 11.6 mi | ★★★★★ | 31 | 0 |
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