Below average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
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 Iola during CMS and state inspections, most recent first.
Annual performance evaluations were not completed for five CNAs and CMAs who had been employed for over a year, despite facility policy requiring formal, written evaluations for all staff. Administrative staff confirmed that these evaluations were not conducted as required.
Surveyors identified unsanitary conditions in the kitchens, including dirty equipment, food debris, sticky floors, and improper hand hygiene by dietary staff. Staff interviews confirmed a lack of regular cleaning schedules and inconsistent adherence to facility policies for cleaning and sanitation.
The facility did not have a certified Infection Preventionist (IP) overseeing the infection prevention and control program. After the previous certified IP left, the current staff member assigned as IP was not certified, contrary to facility policy requiring certification for this role.
A Certified Medication Aide did not complete the required 12 hours of annual education, and administrative staff confirmed the absence of a facility policy on education. The aide verified not having completed the mandatory training, and no policy was provided by the facility.
Residents were not fully informed about their health status, care, and treatments. The facility did not provide adequate communication to ensure that residents understood their medical conditions and the care or treatments being administered.
Multiple areas of the facility, including a resident's room and the dining area, were found to be unclean and in disrepair, with sticky food debris, missing floor tiles creating unmarked tripping hazards, and damaged door frames and doors. Staff interviews confirmed that these issues persisted for weeks without adequate cleaning or safety measures, contrary to facility policy.
The facility did not establish or maintain an infection prevention and control program as required, resulting in a deficiency identified by surveyors.
Two residents had inaccurate Minimum Data Set (MDS) assessments, including errors in documenting fall history and medication use. One resident’s MDS failed to record all recent falls, including one with injury, while another’s MDS incorrectly listed anticoagulant use instead of antiplatelet therapy. Staff confirmed these inaccuracies, which resulted in the residents’ care needs not being properly identified.
Two residents did not have complete care plans addressing their specific needs: one with trigeminal neuralgia lacked non-pharmacological pain interventions in the care plan despite documented pain and medication orders, and another with respiratory failure did not have care plan instructions for oxygen use, even though oxygen therapy was ordered and administered.
A resident with severe cognitive impairment and an indwelling Foley catheter was transferred using a full body lift, during which staff attached the catheter drainage bag above bladder level, contrary to care plan instructions and standard practice. Staff interviews confirmed knowledge of proper catheter bag positioning, but this was not followed during the transfer. The facility did not provide a catheter care policy when requested.
A resident with trigeminal neuralgia did not receive scheduled doses of carbamazepine and lidocaine viscous solution due to a failure to reorder medications in a timely manner, resulting in increased pain and observed facial grimacing. The care plan lacked non-pharmacological interventions, and the facility's pain management policy was not fully implemented.
Staff failed to maintain resident dignity and privacy by transporting a resident through common areas in a shower chair with exposed buttocks and by entering the rooms of three residents without knocking, introducing themselves, or waiting for acknowledgment. Staff interviews confirmed awareness of proper protocols, and facility policy emphasized residents' rights to dignity and privacy.
A resident reported being roughly handled by a CNA, causing dizziness, nausea, and difficulty breathing due to improper bed positioning and lack of oxygen. Despite activating her call light and yelling for help, she did not receive assistance for hours. The incident was not immediately reported to administrative staff, allowing the CNA to continue her shift, placing other residents at risk.
A resident reported that a CNA was rough during a transfer, causing dizziness and difficulty breathing. The resident's call for help was ignored, and the CNA responded rudely. The incident was not reported to administrative staff immediately, allowing the CNA to continue working for eight more hours, putting other residents at risk.
A resident experienced abuse and neglect when a CNA was rough during a transfer, causing dizziness and difficulty breathing. The resident's call light was ignored for hours, and staff failed to report the incident immediately, allowing the CNA to continue working and potentially placing other residents at risk.
A cognitively impaired resident with a history of elopement risk exited the facility unnoticed due to a deactivated door alarm. The resident was found outside by a visitor, highlighting lapses in supervision and safety protocols.
Failure to Complete Annual Performance Evaluations for CNAs and CMAs
Penalty
Summary
The facility failed to complete annual performance evaluations for five Certified Nurse Aides (CNAs) and Certified Medication Aides (CMAs) who had been employed for more than 12 months. Personnel records reviewed showed that these evaluations had not been conducted within the required timeframe, as outlined in the facility's Employee Handbook, which mandates formal, written evaluations for all full and part-time employees. During an interview, administrative staff confirmed awareness of the requirement but acknowledged that the evaluations were not completed for the selected staff members.
Unsanitary Food Storage and Preparation Conditions Identified
Penalty
Summary
Surveyors observed multiple unsanitary conditions in the facility's kitchens, including dried food debris on the automated dishwasher, food particles and storage bags on top of the ice maker, and dirty, dusty fans blowing into food preparation and dish cleaning areas. The kitchen floors were found to be sticky, slick, and littered with food items and trash, while trash cans and counters were visibly dirty. Seven plastic cutting boards were deeply grooved and marked, and three large baking sheets had baked-on grease and cut marks, all of which were acknowledged by the Dietary Manager as unsanitary and in need of replacement. Additionally, a broken tile was noted around a clean-out drain by the stove, and clean dishes were exposed to air from a dirty fan. Staff interviews revealed a lack of regular cleaning schedules for key equipment such as the automated dishwasher, and inconsistent cleaning practices throughout the kitchen. Dietary staff were observed failing to perform hand hygiene or wear gloves when handling resident cups and food, and continued food preparation without proper sanitation. Facility policies required routine cleaning and disinfection, as well as adherence to written cleaning schedules and staff training, but these were not followed as evidenced by the ongoing unsanitary conditions and staff admissions regarding lapses in cleaning and hand hygiene.
Lack of Certified Infection Preventionist
Penalty
Summary
The facility failed to ensure that the designated Infection Preventionist (IP) was trained and certified in infection prevention and control, as required by their own policy and regulatory standards. At the time of the survey, the facility had a census of 43 residents. Interviews with administrative staff revealed that the previous certified IP left the facility on 06/01/25, and the current staff member identified as the IP was not certified in infection control. The facility's Infection Control Surveillance policy, dated 11/2023, specifies that the IP is responsible for monitoring compliance with infection prevention and control standards, but this requirement was not met due to the lack of a certified IP.
Failure to Ensure Mandatory CNA Education Requirements Met
Penalty
Summary
The facility failed to ensure that Certified Nurse Aides (CNAs) completed the mandatory 12 hours of education required within a 12-month period. Review of personnel and training records showed that a Certified Medication Aide (CMA) had not completed any of the required education hours in the last year. During interviews, administrative staff confirmed that there was no facility policy related to education and that the facility relied solely on regulations. The CMA also verified not having completed the mandatory education during the specified period. No policy was provided by the facility regarding staff education requirements.
Failure to Inform Residents of Health Status and Treatments
Penalty
Summary
Residents were not fully informed about their health status, care, and treatments. The facility failed to ensure that residents received adequate information and understanding regarding their medical conditions and the care or treatments being provided. This lack of communication resulted in residents not having the necessary knowledge to make informed decisions about their care. The deficiency was identified through observations and interviews, which revealed that residents did not consistently receive explanations or updates about their health status or the treatments they were receiving.
Failure to Maintain Safe and Clean Environment Creates Tripping Hazards and Discomfort
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for its residents, as evidenced by multiple observations of uncleanliness and physical hazards throughout the building. One resident's fall mat and room floor were found to have sticky food particles and debris, and the mat was described as filthy by a licensed nurse. The dining room floor was missing 44 tiles, creating a tripping hazard that was not marked with any warning signs or barriers. Additionally, door frames and doors in several hallways were observed to have bubbled, chipped, and missing paint, with some doors showing veneer separation. These issues were present in multiple areas, including the 100, 300, and 400 halls. Staff interviews revealed that the missing dining room tiles had been removed three weeks prior due to a plumbing issue, but no temporary safety measures were put in place. Maintenance staff acknowledged ongoing issues with door frame and door repairs, including monthly repainting and attempts to re-glue bubbling laminate. Administrative staff confirmed that floors should be cleaned daily and that maintenance should be notified immediately for repairs, but these practices were not consistently followed. The facility's own policy states that residents have the right to dignity, respect, and proper living arrangements, which were not upheld in these instances.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, indicating that the required measures to prevent and control infections were not established or maintained as per regulatory standards. The report notes the absence of a comprehensive infection prevention and control program but does not provide further details regarding specific actions, inactions, or events, nor does it mention any particular residents or staff involved.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) assessments for two residents, resulting in documentation errors regarding their clinical status and care needs. For one resident with Parkinson’s disease and dementia, the Significant Change MDS incorrectly recorded the number and type of falls, documenting only one non-injury fall when records showed two falls, one of which resulted in a minor injury. Observations confirmed the resident’s high level of dependency and fall risk, and staff interviews acknowledged the MDS inaccuracy. The facility’s own documentation and staff statements confirmed that the MDS did not accurately reflect the resident’s fall history as required by the Resident Assessment Instrument (RAI) manual. For another resident with dementia, the Quarterly MDS inaccurately indicated that the resident received an anticoagulant during the assessment period, when in fact the resident was only receiving an antiplatelet medication (aspirin). The resident’s cognitive status was also documented inconsistently between assessments. Staff interviews confirmed the MDS error, and facility policy required accurate and timely completion of the MDS. These inaccuracies in the MDS assessments placed the residents at risk for impaired care due to unidentified or misidentified care needs.
Failure to Complete Comprehensive Care Plans for Pain and Oxygen Use
Penalty
Summary
The facility failed to complete comprehensive care plans for two residents, resulting in unaddressed care needs. One resident with a diagnosis of trigeminal neuralgia had a care plan that did not include staff instructions for non-pharmacological pain interventions, despite receiving both scheduled and PRN pain medications and reporting pain levels ranging from zero to nine on a one to ten scale. The resident's medical record included physician orders for pain management medications, and staff observed the resident experiencing pain, as evidenced by facial grimacing. The facility's pain management policy required individualized interventions for residents with pain to be documented in the care plan, but this was not done for this resident. Another resident with a diagnosis of respiratory failure and receiving oxygen therapy did not have staff instructions regarding oxygen use included in the care plan. The resident's medical record documented ongoing oxygen use per nasal cannula, as ordered by the physician, and staff observed the resident using oxygen during multiple visits. The facility's policy required the development of a care plan to address each resident's needs, but the omission of oxygen use instructions in the care plan represented a failure to communicate essential care requirements.
Failure to Maintain Proper Catheter Bag Position During Resident Transfer
Penalty
Summary
Staff failed to provide appropriate catheter care for a resident with an indwelling Foley catheter, as observed during a transfer from wheelchair to bed. The resident, who had diagnoses including urinary tract infection, Parkinson's disease, and dementia with severe cognitive impairment, required total assistance and was transferred using a full body lift. During the transfer, staff attached the Foley catheter drainage bag to the sling at the resident's shoulder level, which was above the level of the bladder, contrary to care plan instructions and standard catheter care practices. The bag was later placed level with the bladder and then attached to the bed frame. Interviews with staff confirmed awareness that the catheter drainage bag should remain below the level of the bladder at all times to prevent urine backflow. However, staff admitted to not considering this during the transfer. The facility did not provide a policy for catheter care when requested. This failure to maintain the catheter bag below bladder level during resident transfer constituted a deficiency in providing appropriate catheter care and services.
Failure to Administer Prescribed Pain Medications for Resident with Trigeminal Neuralgia
Penalty
Summary
A resident with a diagnosis of trigeminal neuralgia, a chronic and painful nerve condition, did not receive scheduled pain medications, including carbamazepine and lidocaine viscous solution, as ordered by the physician. The medication administration record showed missed doses over several days, and progress notes indicated that the pharmacy was notified of the need for refills, but the medications were not available or administered during this period. The resident reported increased pain and facial grimacing was observed by staff, with a pain score of nine out of ten documented on the morning following the missed doses. Staff interviews confirmed that the medications were not reordered in a timely manner, resulting in the resident not having access to her prescribed pain management regimen over the weekend. The resident's care plan included pharmacological interventions for pain but lacked direction for non-pharmacological interventions. The facility's pain management policy required individualized treatment plans with both pharmacologic and non-pharmacologic interventions for residents experiencing pain. Despite this, the resident's care plan was incomplete, and the failure to ensure timely medication refills and administration led to unmanaged pain for the resident.
Failure to Maintain Resident Dignity and Privacy
Penalty
Summary
Staff failed to protect the dignity and privacy of three residents through several observed actions. One resident was transported from his room to the shower room in a shower chair covered only with a white sheet, leaving his buttocks exposed as he was wheeled past the dining area where other residents were present. Staff interviews confirmed that this method of transport was not appropriate or dignified, and that residents were typically moved in their wheelchairs, fully clothed or covered. Additionally, staff repeatedly entered the rooms of three residents without knocking, introducing themselves, or waiting for acknowledgment. Observations showed staff opening closed doors and entering rooms while residents were present, sometimes during interviews, without following proper protocols for privacy and respect. Multiple staff members, including CNAs and nurses, acknowledged in interviews that the expected practice was to knock, introduce themselves, and await acknowledgment before entering a resident's room. The facility's policy also documented residents' rights to dignity, respect, and privacy.
Failure to Prevent Abuse and Neglect of Resident
Penalty
Summary
The facility failed to prevent the physical abuse and neglect of a resident (R2) by a Certified Nurse Aide (CNA M). On the evening in question, R2 reported that CNA M was rough while assisting her to bed, throwing her into bed by holding her legs and swinging her while in the lift sling. This improper handling caused R2 to experience dizziness, nausea, and difficulty breathing due to the bed being left flat and the lack of supplemental oxygen. Despite activating her call light and yelling for help, R2 did not receive assistance for 3 to 3.5 hours until another CNA (CNA N) arrived for the night shift. When CNA N responded, she found R2 crying and upset, and CNA M yelled at R2 from the hallway, further exacerbating the situation. CNA N reported the incident to Licensed Nurse (LN G), who also failed to report the abuse and neglect to the administrative staff immediately, allowing CNA M to continue her shift for eight more hours, placing other residents at risk for abuse and neglect. R2's medical records indicated she had muscle weakness, anxiety disorder, and chronic obstructive pulmonary disease (COPD), requiring oxygen at night to maintain oxygen saturations above 90 percent. R2 was assessed with intact cognition and required extensive assistance from two staff members for bed mobility and transfers with a full-body lift. The facility's investigation revealed that R2 had been left in a flat position without oxygen, causing her significant distress. Multiple staff members, including CNA N and LN G, witnessed R2's distress and reported the incident, but the reports were not immediately escalated to the administrative staff as required by the facility's policy. The facility's policy for Abuse, Neglect, and Exploitation mandates immediate reporting of any alleged violations involving abuse, neglect, exploitation, or mistreatment to the Administrator or their designated representative. However, this policy was not followed, as evidenced by the delayed reporting and the continued presence of CNA M in the facility. The failure to adhere to the policy and the improper handling of R2 by CNA M resulted in immediate jeopardy for R2 and other residents in the facility.
Removal Plan
- Administrative Staff A and Administrative Nurse D interviewed R2. R2 confirmed the allegations.
- CNA M interviewed by Administrative Staff A and Administrative Nurse D and asked if she had done all the things reported and CNA M responded yes and began crying. CNA M suspended.
- CNA M interviewed by Administrative Staff A regarding the allegations against CNA N to R2.
- The LN completed an assessment.
- Verbal discipline and education given to LN G for not reporting immediately.
- All staff training initiated immediately on reporting allegations of abuse and completed at the start of each shift.
- Written discipline given to LN G.
- QAPI meeting held with the medical director.
- CNA M terminated.
Failure to Report Abuse and Neglect Immediately
Penalty
Summary
The facility failed to report abuse and neglect of a resident immediately. On the evening of 03/21/24, a resident reported that a Certified Nurse Aide (CNA) was rough with her during a transfer from her wheelchair to her bed, causing her to feel dizzy, nauseous, and have difficulty breathing. The resident activated her call light and yelled for help, but the CNA responded by yelling back from the hallway and did not assist her. The resident remained in an uncomfortable and unsafe position without her supplemental oxygen for several hours until another CNA arrived for the night shift and provided the necessary assistance. The incident was reported to a Licensed Nurse (LN) at 10:10 PM, but the LN and the CNA who discovered the resident's distress did not report the abuse and neglect to the administrative staff immediately. The administrator only became aware of the situation the following morning after reading the Report of Concern forms. The CNA involved in the incident continued to work her shift for eight more hours, potentially putting other residents at risk. The resident involved had a medical history of muscle weakness, anxiety disorder, and chronic obstructive pulmonary disease (COPD). She required oxygen at night and extensive assistance from staff for bed mobility and transfers. The facility's failure to report the abuse and neglect immediately allowed the CNA to remain on duty, which placed the resident and potentially other residents in immediate jeopardy.
Removal Plan
- Administrative Staff A and Administrative Nurse D interviewed R2. R2 confirmed the allegations.
- CNA M interviewed by Administrative Staff A and Administrative Nurse D and admitted to the allegations. The facility suspended CNA M.
- CNA M interviewed by Administrative Staff A regarding the allegations against CNA N to R2.
- The LN completed an assessment.
- Verbal discipline and education given to LN G for not reporting immediately.
- All staff training initiated immediately on reporting allegations of abuse, and completed at the start of each shift.
- Written discipline given to LN G.
- QAPI meeting held with the medical director.
- CNA M terminated.
Failure to Protect Resident from Abuse and Neglect
Penalty
Summary
The facility failed to protect a resident from further abuse and neglect when staff did not immediately notify the administrator of an allegation of abuse. The incident occurred when a Certified Nurse Aide (CNA) was reported to have been rough with the resident during a transfer to bed, causing the resident to experience dizziness, nausea, and difficulty breathing. The resident's call light was not answered for several hours, and when another CNA arrived, the resident was found crying and upset. Despite being informed of the situation, the staff did not report the abuse immediately to the administrator, allowing the CNA to continue working for eight more hours, potentially placing other residents at risk. The resident involved had a medical history that included muscle weakness, anxiety disorder, and chronic obstructive pulmonary disease (COPD). The resident required oxygen and had limited use of her right arm, necessitating total assistance from staff for bed mobility and transfers. On the night of the incident, the resident was left in a flat position without her supplemental oxygen, which exacerbated her symptoms. The resident's oxygen saturation level was documented at 85 percent, significantly lower than her usual levels. The facility's policy required immediate reporting of any allegations of abuse, neglect, or exploitation to the administrator. However, the staff failed to follow this policy, resulting in a delay in addressing the resident's concerns and removing the CNA from duty. The failure to report the incident promptly and the continued presence of the CNA in the facility constituted a serious deficiency in the facility's duty to protect its residents from abuse and neglect.
Removal Plan
- Administrative Staff A and Administrative Nurse D interviewed R2. R2 confirmed the allegations.
- CNA M interviewed by Administrative Staff A and Administrative Nurse D and asked if she had done all the things reported and CNA M responded yes and began crying. CNA M suspended.
- CNA M interviewed by Administrative Staff A regarding the allegations against CNA N to R2.
- The LN completed an assessment.
- Verbal discipline and education given to LN G for not reporting immediately.
- All staff training initiated immediately on reporting allegations of abuse and completed at the start of each shift.
- Written discipline given to LN G.
- QAPI meeting held with the medical director.
- CNA M terminated.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to provide adequate supervision and a safe environment for a cognitively impaired and independently mobile resident identified as an elopement risk. On one occasion, staff deactivated an exit door alarm due to a storm, which led to the resident exiting the facility without staff knowledge. The resident was found outside by a visitor, who then informed the facility staff. The resident had a history of Alzheimer's disease, dementia, and hallucinations, and was assessed with severe cognitive impairment and a high elopement risk level. Despite these known risks, the facility did not ensure that the exit door alarms were functioning, nor did they provide appropriate supervision for the resident, who had previously displayed exit-seeking behaviors. The resident's care plan included interventions such as structured activities, reorientation strategies, and monitoring for wandering patterns. However, these measures were not effectively implemented, as evidenced by the resident's ability to exit the facility unnoticed. Staff members who were present during the incident did not hear any door alarms, and the door that the resident exited from was found to be unlocked and unalarmed. Multiple staff members provided witness statements indicating that they were unaware of the resident's whereabouts until alerted by the visitor. The facility's failure to maintain functioning door alarms and provide adequate supervision placed the resident in immediate jeopardy. The incident highlighted significant lapses in the facility's safety protocols and staff awareness, which ultimately led to the resident's elopement. The facility's policies and procedures for monitoring and preventing elopement were not effectively followed, resulting in a serious deficiency in resident care and safety.
Removal Plan
- The facility immediately placed R1 on one-to-one supervision with staff, after the nurse assessed for injuries when he returned back inside the building.
- A facility wide door check completed by maintenance to ensure all alarmed doors were in proper working order.
- R1's elopement assessment updated, and all other residents has elopement assessment completed and care plan reviewed for accuracy and appropriateness.
- Stop signs placed on hallway exit doors to remind resident to turn around.
- The facility's Elopement book reviewed to ensure accurate content.
- The Administrator, Director of Nursing, and Medical Director held a QAPI (Quality Assurance Performance Improvement) meeting via phone.
- All staff educated on elopement policy and resident incident. Otherwise, employees were suspended pending required in-service.
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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.
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Nursing homes near Iola
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Moran Manor | 12.2 mi | ★★★★★ | 0 | 0 |
| Heritage Health Care Center | 18.1 mi | ★★★★★ | 8 | 0 |
| Diversicare Of Chanute | 18.7 mi | ★★★★★ | 19 | 0 |
| Yates Operator, Llc | 19.1 mi | — | 0 | 0 |
| Anderson County Hospital Ltcu | 25.3 mi | ★★★★★ | 0 | 0 |
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