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 Leavenworth during CMS and state inspections, most recent first.
The facility did not ensure RN coverage for eight consecutive hours daily, as required, due to missing documentation and lack of policy. This affected 34 residents, placing them at risk of inadequate assessment and care.
The facility failed to complete the required yearly performance evaluations for three CNAs, placing residents at risk for inadequate care. The CNAs, employed for over 12 months, had no evaluations or in-service records available. Administrative Staff confirmed the absence of these records, and the facility lacked a policy on staff competency, training, or evaluations.
The facility did not employ a full-time certified dietary manager for its 34 residents, risking inadequate nutrition. Dietary Staff BB had not started classes to become certified, and the facility relied on a monthly visiting Registered Dietician. Administrative Staff B confirmed the absence of a Certified Dietary Manager, and no policy was in place for this role.
The facility did not designate a qualified Infection Preventionist (IP) employed at least part-time, as required. Administrative Staff C was acting as the IP, but it was revealed that a consultant, not directly employed by the facility, was performing IP duties. This deficiency placed all residents at risk due to the lack of proper infection identification, tracking, trending, and treatment.
The facility failed to ensure a CNA completed the required 12 hours of in-service education over the past year. This deficiency was confirmed by administrative staff, and the facility lacked a policy related to staff training, contributing to the issue.
The facility failed to ensure controlled substances were properly accounted for and reconciled between shifts, risking medication misappropriation and diversion. Missing signatures on Controlled Medication Shift Count Sheets for July, August, and September 2024 indicated non-compliance with procedures requiring narcotics to be counted at every shift change. Staff interviews confirmed the expectation for narcotics counting, but the facility did not ensure accurate reconciliation, violating federal and state regulations.
The facility failed to implement an effective infection prevention and control program, lacking signage for Enhanced Barrier Precautions (EBP) and PPE availability for residents with open wounds and catheters. Shared equipment was not sanitized between uses, and staff did not perform adequate hand hygiene. Respiratory equipment was improperly stored, increasing the risk of infectious diseases.
A resident with a history of COPD, CHF, myocardial infarction, and leukemia, and severely impaired cognition, was at risk for pressure ulcers and had existing ones. Despite the care plan requiring the resident's heels to be floated on a pillow, observations showed this was not done, and pressure-relieving boots were not used. Staff confirmed care plans were accessible, but the failure to follow them increased the risk of worsening the resident's condition.
A resident with a suprapubic catheter did not have a stat-lock properly placed, as required by their care plan, leading to a deficiency in catheter management. The resident reported issues with the stat-lock not staying in place due to pulling, and staff interviews revealed a lack of clarity on proper placement. The facility could not provide a catheter care policy, indicating a failure to follow standard practices, placing the resident at risk for complications.
A resident with sleep apnea and other medical conditions was found to have their CPAP mask stored unsanitarily on a bedside table, increasing the risk of respiratory infection. Despite staff acknowledging the need for sanitary storage in a plastic bag, the facility lacked a policy to ensure compliance, leading to this deficiency.
The facility failed to ensure comprehensive monthly drug regimen reviews for several residents, leading to deficiencies in medication management. A resident did not receive a recommended gradual dose reduction for Ambien, and the physician did not review the consultant pharmacist's recommendations. Another resident's medication regimen lacked physician documentation of the pharmacist's recommendations, and a third resident was prescribed an antipsychotic without a CMS-approved indication. These failures placed residents at risk for unnecessary medication use and adverse side effects.
A facility failed to ensure a CMS-approved indication or required physician documentation for the use of antipsychotic and hypnotic medications for two residents. One resident received Risperdal without a GDR attempt or documentation, while another received hypnotic medications without a GDR or drug regimen review. The facility's policy required monthly medication reviews, but these were not conducted, placing residents at risk for unnecessary medication use and adverse effects.
A facility failed to ensure proper collaboration and communication with a hospice provider for a resident with chronic obstructive pulmonary disease and severely impaired cognition. The care plan lacked documentation of hospice-covered medications, personal care items, and medical equipment. Staff interviews revealed uncertainty about hospice services, and the facility lacked a policy for hospice care collaboration.
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. The facility's census at the time was 34 residents. Administrative Staff C indicated that the previous Director of Nursing, a salaried employee, was supposed to provide RN coverage on those dates, but there was no documentation to verify her working the required hours. Additionally, the facility did not have a policy related to RN coverage. This lack of RN coverage placed all residents at risk of lack of assessment and inappropriate care.
Deficiency in CNA Performance Evaluations
Penalty
Summary
The facility, with a census of 34 residents, was found to have deficiencies in the performance evaluations and in-service training of its Certified Nurse Aides (CNAs). A sample review of 12 residents and three CNAs revealed that the facility failed to complete the required yearly performance evaluations for all three CNAs reviewed. Specifically, CNA Q, hired on June 30, 2022, CNA R, hired on March 22, 2019, and CNA MM, hired on February 8, 2022, had no performance evaluations available upon request. Administrative Staff C confirmed the absence of these evaluations and the required in-service records. Additionally, the facility did not provide a policy related to staff competency, training, or performance evaluation. This lack of evaluations placed residents at risk for inadequate care.
Lack of Certified Dietary Manager Puts Residents at Nutritional Risk
Penalty
Summary
The facility failed to employ a full-time certified dietary manager for its 34 residents, which placed them at risk for inadequate nutrition. Dietary Staff BB, who was responsible for dietary management, had not yet started classes to become a Certified Dietary Manager and was attempting to enroll in such a class. The facility relied on a Registered Dietician who visited monthly and could be contacted via email for changes to diets or menus. Administrative Staff B confirmed the absence of a Certified Dietary Manager and noted that the dietary manager was enrolled in a class. The facility did not have a policy in place for a Certified Dietary Manager, contributing to the deficiency in nutritional oversight and management.
Failure to Designate Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a qualified Infection Preventionist (IP) who was employed by the facility at least part-time, as required for the Infection Prevention and Control Program. During the entrance conference, Administrative Staff C stated she was acting as the IP and had been onsite for 45 days. However, it was later revealed by Administrative Nurse A that the facility did not have a designated IP at that time. Instead, Administrative Nurse C, a consultant not directly employed by the facility, was performing the IP duties. This lack of a qualified and certified IP employed by the facility placed all residents at risk due to the absence of proper identification, tracking, trending, and treatment of infections.
Deficiency in CNA In-Service Training
Penalty
Summary
The facility failed to ensure that one of the three Certified Nurse Aides (CNAs) reviewed had completed the required 12 hours of in-service education, which is necessary for maintaining the skills needed to care for residents. Specifically, CNA Q, who was hired on June 30, 2022, had not completed any of the required in-services in the past 12 months. This deficiency was confirmed by Administrative Staff C on September 24, 2024, and further acknowledged by Administrative Staff B on September 25, 2024, who mentioned that improving the process of yearly performance reviews was a focus for the new management team. Additionally, the facility was unable to provide a policy related to staff training, which contributed to the deficiency.
Failure to Reconcile Controlled Substances
Penalty
Summary
The facility failed to ensure that controlled substances were properly accounted for and reconciled between shifts, which placed residents at risk for misappropriation and/or diversion of these medications. The facility had a census of 34 residents and utilized one medication room and two medication carts, one for scheduled medications and another for narcotics and treatments. Upon review of the Controlled Medication Shift Count Sheets for July, August, and September 2024, it was found that there were missing signatures for both on-coming and off-going nurses on multiple dates, indicating a failure to follow the established procedure for counting narcotics at every shift change. Interviews with staff revealed that the procedure required nurses to count narcotics with every shift change, as confirmed by Licensed Nurse G and Administrative Nurse D. The facility's policy on Medication Storage Controlled Medication Storage, dated January 2024, required special handling, storage, disposal, and record-keeping for controlled substances in compliance with federal, state, and other applicable laws and regulations. Despite these requirements, the facility did not ensure accurate reconciliation of controlled medications, thereby placing residents at risk of medication misappropriation and diversion.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to implement an effective infection prevention and control program, as evidenced by several deficiencies observed during a survey. The survey revealed that the facility did not have appropriate signage or indicators to alert staff and visitors of residents on Enhanced Barrier Precautions (EBP). Additionally, personal protective equipment (PPE) was not readily available in the rooms of residents who required EBP due to conditions such as open wounds and catheters. This lack of signage and PPE availability was noted in the rooms of multiple residents, including those with wound vacs, suprapubic catheters, and Foley catheters. Further deficiencies were observed in the facility's failure to sanitize shared equipment between uses and ensure adequate hand hygiene by staff. For instance, a Certified Nurse Aide (CNA) did not perform hand hygiene after providing peri care and handling a Hoyer lift, which was then not disinfected before being moved to the hallway. Additionally, respiratory equipment was not stored in a sanitary manner, as evidenced by an oxygen nasal cannula being draped over a bed rail instead of being contained in a sanitary container. These practices placed residents at risk for infectious diseases.
Failure to Implement Pressure-Reducing Interventions for a Resident
Penalty
Summary
The facility failed to implement pressure-reducing interventions for a resident identified as R16, who was at risk for pressure ulcer development and had existing pressure ulcers. R16's medical history included chronic obstructive pulmonary disease, congestive heart failure, myocardial infarction, and leukemia, with severely impaired cognition and mobility issues. The Minimum Data Set (MDS) indicated that R16 was at risk for pressure ulcers and required pressure-reducing devices for both the chair and bed. The care plan specified that R16's heels should be floated on a pillow while in bed to prevent further skin breakdown. Despite these documented needs, observations revealed that R16's heels were not floated on a pillow as required, and the blue foam boots intended for pressure relief were found on the bedside table instead of being used. Interviews with staff, including a CNA and a licensed nurse, confirmed that care plans were accessible and that important information was communicated during daily reports. However, the failure to ensure R16's heels were properly supported as per the care plan increased the risk of pressure ulcer development and worsening of the existing left heel wound.
Deficiency in Catheter Care for Resident with Suprapubic Catheter
Penalty
Summary
The facility failed to ensure proper care for a resident with a suprapubic catheter, leading to a deficiency in catheter management. The resident, identified as R26, had a history of urinary retention, Parkinson's disease, and diabetes mellitus, and required assistance with personal care. The resident's care plan specified that a catheter stat-lock should be used to prevent injury or pulling of the catheter. However, during an observation, it was noted that the resident did not have a stat-lock in place, and the resident reported that the stat-lock was usually placed on his inner left leg but would not stay in place due to the catheter tubing pulling it loose. Further interviews with staff revealed a lack of clarity and adherence to the standard of practice for the placement of the stat-lock. A CNA mentioned the need to clarify the placement with the charge nurse, while a licensed nurse and an administrative nurse both stated that the stat-lock should be placed on the abdomen to prevent pulling on the catheter tube. The facility was unable to provide a policy related to catheter care, indicating a gap in ensuring the standard of practice was followed. This deficiency placed the resident at risk for catheter-related complications.
Failure to Maintain Sanitary Storage of CPAP Equipment
Penalty
Summary
The facility failed to ensure the sanitary storage of a CPAP mask and nasal cannula for a resident, identified as R27, who was at increased risk for respiratory infection and complications. R27's medical history included conditions such as sleep apnea, hypertension, obesity, and osteomyelitis, among others. The resident was dependent on staff for all activities of daily living except eating and required a non-invasive mechanical ventilator. Observations revealed that R27's CPAP mask was repeatedly left on the bedside table without being stored in a sanitary container, contrary to the care plan and physician orders that specified regular cleaning and proper storage of the respiratory equipment. Interviews with facility staff, including a CNA, a licensed nurse, and an administrative nurse, confirmed that respiratory equipment should be stored in a plastic bag with the date on it and changed weekly. However, the facility did not provide a policy related to the care and sanitary storage of respiratory equipment. This oversight in maintaining sanitary conditions for R27's CPAP mask and nasal cannula was identified as a deficiency, as it placed the resident at an increased risk for respiratory infection and complications.
Deficiencies in Medication Regimen Review and Physician Oversight
Penalty
Summary
The facility failed to ensure that a licensed pharmacist performed a comprehensive monthly drug regimen review (MRR) for several residents, leading to deficiencies in medication management. For Resident 3, the facility did not ensure that the consultant pharmacist (CP) identified and recommended a gradual dose reduction (GDR) for the hypnotic medication Ambien. Additionally, there was no evidence that the physician reviewed or addressed the CP's recommendations for Resident 3's medication regimen from May to July 2024. This oversight placed Resident 3 at risk for unnecessary medication administration and potential adverse side effects. Resident 26 also experienced deficiencies in medication management, as the facility failed to ensure that the CP's monthly recommendations were reviewed or addressed by the physician. The MRRs for Resident 26 from February to June 2024 lacked evidence of physician documentation of the CP's recommendations. This failure to conduct a thorough MRR placed Resident 26 at risk for unnecessary medications and adverse side effects. For Resident 9, the facility did not ensure that the CP identified and reported the lack of a CMS-approved indication for the antipsychotic medication Risperdal. The clinical record lacked physician documentation of a rationale for the continued use of Risperdal without a GDR attempt. This deficiency placed Resident 9 at risk for unnecessary medication administration and possible adverse side effects. The facility's failure to adhere to its Medication Regimen Review and Reporting policy contributed to these deficiencies.
Failure to Ensure GDR and Documentation for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that Resident 9 had a CMS-approved indication for the use of an antipsychotic medication, Risperdal, or the required physician documentation. The resident's electronic medical record documented diagnoses of bipolar disorder, delusions, anxiety, and cognitive communication deficit, with severely impaired cognition as indicated by a BIMS score of one. Despite receiving antipsychotic and antidepressant medications, no gradual dose reduction (GDR) was attempted or documented as contraindicated by the physician. The facility's records lacked evidence of physician documentation for the continued use of Risperdal without a CMS-approved indication or GDR attempts, placing the resident at risk for unnecessary medication administration and adverse side effects. Additionally, the facility did not ensure that Resident 3 had a GDR or the required physician documentation for the use of hypnotic medications. The resident's electronic medical record showed diagnoses of paraplegia, mild cognitive impairment, depression, and anxiety, with intact cognition as indicated by a BIMS score of 15. The resident received antidepressant, antianxiety, hypnotic, and opioid medications, but no GDR or drug regimen review was completed during the observation period. The facility's records lacked evidence of a GDR attempt or documentation as contraindicated by the physician, placing the resident at risk for unnecessary medication administration and adverse side effects. The facility's policy on Behavior Management and Psychotropic Medications, last revised in December 2022, required the consultant pharmacist to complete a monthly Medication Regimen Review and provide information to the physician and facility regarding GDR or continued use when indicated. However, the facility failed to adhere to this policy for both residents, as evidenced by the lack of GDR attempts and necessary documentation. This oversight placed the residents at risk for unnecessary medication use and potential adverse effects.
Deficiency in Hospice Care Coordination for a Resident
Penalty
Summary
The facility failed to ensure proper collaboration and communication between the nursing home and the hospice provider for Resident 8, who was receiving hospice care. The resident's care plan lacked documentation regarding the medications covered by hospice, personal care items, and medical equipment provided by hospice. Despite the care plan indicating that the hospice provider's certified nurse aide would visit twice weekly and the hospice nurse would visit weekly, there was no clear documentation of these arrangements. This lack of documentation and communication created a risk of missed opportunities for services and delayed addressing the resident's physical, mental, and psychosocial needs. Resident 8 had a history of chronic obstructive pulmonary disease, depression, and altered mental status, with a BIMS score indicating severely impaired cognition. The resident reported constant pain and required assistance with activities of daily living. Interviews with facility staff revealed uncertainty about the hospice services provided, as the Kardex did not clearly list the medical equipment or the schedule of hospice CNA visits. The facility was also unable to provide a policy related to the collaboration of care with the hospice provider, further highlighting the deficiency in ensuring a collaborative process for the resident's care.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 370 citations issued within 25 miles in the last 12 months — including the 6 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Leavenworth
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Twin Oaks Health And Rehab | 3.6 mi | ★★★★★ | 0 | 0 |
| Lansing Care And Rehab | 3.7 mi | ★★★★★ | 22 | 0 |
| Aspire Senior Living Platte City | 9.1 mi | ★★★★★ | 1 | 0 |
| Easton Health Care Center | 10.2 mi | ★★★★★ | 14 | 0 |
| The Healthcare Resort Of Kansas City | 14.6 mi | ★★★★★ | 32 | 0 |
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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.