Below average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Medicalodges Paola during CMS and state inspections, most recent first.
Food storage and kitchen sanitation practices were deficient when unlabeled and undated food items were found in dry storage and refrigerators, scratched and cracked food-contact equipment was observed, and uncovered dishes were left exposed in the dish storage area. The dishwasher was also run below the manufacturer’s stated minimum wash and rinse temperature, and staff reported documenting average temperatures rather than actual readings.
Staff failed to store respiratory equipment in sanitary containers and failed to follow laundry infection control practices. A resident’s CPAP mask, another resident’s nasal cannula, and nebulizer mask were observed left on furniture or the floor when not in use, while trash bags were left on the floor, dirty linen was carried down the hall against staff clothing, clean laundry was moved in an uncovered cart, and the laundry area lacked PPE for sorting soiled linen and had lint buildup in the dryer.
Failure to Maintain a Clean, Homelike Environment: Surveyors observed dirty floors, stained wall coverings, dirty handrails, smudged windows, and an unclean smoking area with food debris, cigarette butts, flies, and uncovered garbage cans. Resident rooms and bathrooms also had gouged walls, loose trim, grime around toilets, and a cracked toilet bowl. Staff acknowledged the conditions and reported routine cleaning and maintenance processes, but the areas remained dirty and damaged.
Failure to Obtain Informed Consent for Psychotropic Medication: A resident receiving zolpidem for insomnia had EMR documentation showing the medication order and monitoring instructions, but no evidence of education or informed consent for the psychotropic/hypnotic medication. An LPN stated an admin nurse would complete psychotropic consents, and an admin nurse later confirmed she could not locate a consent for the medication.
Resident trust account access was not provided the same day when a resident requested $30 on a weekend. Staff told the resident only $2 was available during weekend money pass because of limited cash in the box and offered to help complete a request form for Monday. Records showed the resident had $1,648.57 in the trust account, and admin staff stated residents could request more than $2 if needed and should not be denied money when funds were available.
A resident with foot drop, narcolepsy, intact cognition, and multiple falls had repeated shower and wheelchair-related falls, but the facility’s fall documentation did not consistently include thorough investigations or complete event details. The resident was also propelled in a wheelchair by a consultant without foot pedals, and staff acknowledged that fall events should have triggered incident reporting, assessment, and updated care planning.
Improper Storage of Respiratory Equipment: A resident with COPD, pneumonia, acute chronic respiratory failure with hypoxia, and OSA had CPAP, O2 tubing, and nebulizer equipment observed stored unsafely, including a nasal cannula on the floor and a CPAP mask on the bed or over the O2 concentrator rather than in a sanitary container or bag. Staff gave inconsistent descriptions of how the equipment should be stored, and the facility could not provide a policy on respiratory equipment storage.
A resident consented to receive PCV20 after previously receiving Pneumovax 23, but the chart lacked documentation that the vaccine was administered. An RN stated that when a resident consents to a vaccine, it is ordered and given, and the facility policy required residents to be offered influenza and pneumococcal vaccines per CDC guidance.
Failure to administer a consented pneumococcal vaccine: a resident had prior Pneumovax 23 and later consented to PCV20, but the chart lacked documentation that the vaccine was given. An Administrative Nurse stated that once consent is obtained, the vaccine is ordered and administered, and the facility policy required eligible residents to be offered pneumococcal vaccines with CDC VIS education.
The facility failed to submit complete and accurate PBJ staffing data to CMS based on payroll and other verifiable records. CMS PBJ data for two quarters showed excessively low weekend staffing, and an admin staff member stated staffing information was sent to corporate for CMS submission but could not confirm whether the data submitted was incorrect. The facility could not provide a PBJ policy.
Surveyors identified unsanitary conditions in the kitchen, including dirty hand-washing sinks, food debris in storage areas, unsanitizable cutting boards, and worn refrigerator racks. These findings indicated that food was not being prepared and served under sanitary conditions, as required by facility policy.
A CNA did not complete the required 12 hours of annual education, as confirmed by a review of training records and staff interviews. The facility had an online system and monitoring process in place, but the CNA's file showed no evidence of completed training for the past year.
Surveyors found that several resident rooms were not maintained in a clean or homelike condition, with issues such as black substance build-up around toilets, unrepaired wall damage, separated cove base, and missing paint. Maintenance staff confirmed the need for repairs, and no housekeeping or maintenance policy was provided.
A resident with hypertension had multiple physician orders for antihypertensive medications, including a PRN order for clonidine to be given when systolic blood pressure exceeded 160 mmHg. Despite several documented high blood pressure readings, staff did not administer the PRN medication or document follow-up, and interviews revealed staff were unaware of the PRN order. The facility did not provide a relevant policy.
Staff did not consistently implement Enhanced Barrier Precautions for two residents with open wounds, as required by facility policy. Observations showed a lack of PPE and signage in the residents' rooms, and staff reported using only gloves during wound care, omitting gowns. There was inconsistent understanding among staff regarding when EBP PPE should be used, despite the facility's infection control policy.
The facility did not ensure that daily nurse staffing sheets included all required information, such as staff hours and census, with only first shift data consistently posted and actual hours worked missing. Administrative and nursing staff confirmed incomplete documentation, and no policy on sufficient staffing was provided.
A resident with multiple health conditions was injured during a transfer when staff used an improperly sized gait belt instead of a mechanical lift. Despite the resident's known weakness and need for assistance, staff attempted to stand the resident, resulting in a fall and a fracture. The facility failed to update the care plan and provide necessary equipment, leading to neglect.
A resident with a history of mental health disorders eloped from the facility without staff knowledge, leading to law enforcement involvement. The facility failed to report the incident to the State Agency, placing the resident in immediate jeopardy. The resident was later retrieved by a nurse in her personal vehicle, despite not being an approved driver.
A resident with a history of mental health disorders and falls exited a facility unsupervised, leading to an incident at a gas station where he threatened a clerk. The facility was unaware of his absence until law enforcement intervened. A nurse, not authorized to transport residents, used her personal vehicle to return the resident, who attempted to grab the steering wheel during the drive. This incident revealed lapses in supervision and protocol adherence.
Food Storage, Dishwashing, and Equipment Sanitation Deficiencies
Penalty
Summary
The facility failed to store and prepare food under sanitary conditions. During observation of the kitchen and food storage areas, surveyors found a large storage bin of sugar in dry storage with no date, several small bowls of green pudding-like mixture in the walk-in refrigerator with no date and no label, and a lunch meat sandwich in the three-bay refrigerator with no label and no date. Dietary staff confirmed that food items should be labeled and dated. Surveyors also observed a white cutting board with several deep scratches on both sides and five silicone food scrapers with cracks and gouges on the sides, and dishes in the storage table were left face up and uncovered while a delivery person walked past them several times during food delivery. Surveyors observed the dishwasher in use and documented wash and rinse temperatures of 112 degrees F and 116 degrees F. The dishwasher temperature log for July 2026 showed no wash or rinse temperatures reaching 120 degrees F, with recorded wash temperatures ranging from 100 degrees F to 118 degrees F and rinse temperatures ranging from 106 degrees F to 118 degrees F. The dishwasher’s manufacturer plate stated a minimum of 120 degrees F for wash and rinse. Dietary staff reported documenting average temperatures rather than the actual readings and could not recall ever documenting 120 degrees F. The certified dietary manager stated she had been told the machine only needed to be 100 degrees F, but after reviewing the manufacturer label, she acknowledged the stated minimum temperature. Administrative staff also stated that food should be labeled and dated, the dishwasher should run at the correct temperature, dishes should be stored properly, and cooking equipment should be without scratches and cracks.
Infection Control Failures in Respiratory Equipment and Laundry Handling
Penalty
Summary
Provide and implement an infection prevention and control program was not adequately carried out when staff failed to store respiratory equipment in a sanitary manner and failed to follow laundry and housekeeping infection control practices. On 07/12/2026, R27’s nasal cannula was observed lying on the floor of his room and his nebulizer mask was lying directly on the dresser, with no containers available for storage when not in use. On 07/12/2026 and again on 07/13/2026, R2’s CPAP mask was observed lying on the dresser and later on the bed, and R2 stated he had no bag to put the CPAP in when he took it off. Staff interviews confirmed that nebulizer masks should be rinsed, air dried, and stored in a bag, oxygen nasal cannulas should be placed inside a bag when not in use, and CPAP masks should be stored in a sanitary container or cabinet when not in use. The facility also failed to maintain laundry and housekeeping practices as described in its policies. A white trash bag was observed on the floor near the laundry door and later outside a resident room across from the nurse’s desk. Housekeeping staff was observed carrying dirty blankets and sheets next to her body, touching her clothing, while moving them down the hall to a grey clothing tub. Clean laundry was observed being pushed down the hall in a cart that was not covered on one side. On 07/14/2026, the laundry department had no PPE available for sorting soiled linen, and the dryer contained two dust pans scoops of lint. Facility staff stated trash bags should not be left on the floor, dirty laundry should not be carried down the hall, clean laundry should be transported in a covered cart, and lint traps should be cleaned daily, while the facility’s policies required gloves and aprons or gowns for soiled linen handling and daily lint removal.
Failure to Maintain a Clean, Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, homelike environment. Survey observations on 07/12/2026 found dirty brown floors throughout the building, including coffee stains, stuck-on food in the dining room, mud tracks, shoe prints, black scuff marks, and dirty brown stains on the blue and green carpeted wall coverings. The exit from the dining room to the designated smoking area had dirty windows and door glass with smudge marks and dirt, and the smoking area contained a broken-lid garbage can, food debris including a half-eaten apple, bread with bite marks, banana peels, cigarette butts on the ground, a dirty picnic table with spilled liquids and food, flies, and another garbage can without a bag or lid that also contained garbage and flies. Resident room and bathroom observations also showed poor environmental conditions. In one room, the walls behind two residents’ beds had gouges down to the plaster and a footboard was loose. In another resident’s bathroom, the area around the base of the toilet had black and brown grime, and a shared bathroom used by four men had a dirty floor, brown substance on the baseboard, and a toilet bowl that was discolored yellow and cracked. Additional hallway observations showed dirty handrails with dried black areas and dust on the wood backing, along with continued dirty floors and brown smears on the wall coverings. Staff interviews confirmed the conditions and described routine cleaning and maintenance processes. Housekeeping staff stated resident rooms and bathrooms were cleaned daily and floors were mopped as needed and daily, while the maintenance/housekeeping supervisor reported the floor cleaner had broken the prior week, the wall coverings had been cleaned last year and were planned for removal, and the smoking area was supposed to be cleaned each morning by the activity department. The supervisor also acknowledged dirty handrails, dirty windows, garbage cans that should have had lids and bags, cigarette butts on the ground, damaged room trim, gouged walls, a loose footboard, and a cracked toilet bowl. Administrative staff stated the facility was expected to be homelike, and no policy for a homelike environment was provided.
Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to inform Resident 27 and/or his representative about the risks related to zolpidem, a psychotropic/hypnotic medication, to support informed consent for the medication. Resident 27’s EMR documented insomnia, and his MDS assessments showed a BIMS score of 12 on admission and later 15 on a quarterly assessment. His records also showed he was receiving zolpidem 5 mg by mouth at bedtime, and his care plan directed staff to administer medications as ordered and monitor for side effects, including abnormal dreams, altered mental status, changes in sleep pattern, dizziness, and rash. The EMR did not contain evidence that Resident 27 or his representative received education or informed consent for zolpidem. During interview, the resident was observed lying in bed and reported feeling lousy and having lung cancer. A licensed nurse stated that an administrative nurse would complete informed consents for psychotropic medications, and an administrative nurse later reviewed the record and could not locate an informed consent for zolpidem, stating she expected all psychotropic medications to have informed consent. The facility policy stated psychotropic medications are not to be initiated without prior communication and documentation of informed consent from the physician, resident or responsible party, and the interdisciplinary team.
Resident Trust Account Access Delayed
Penalty
Summary
The facility failed to ensure a resident’s trust account was accessible the same day when the resident requested thirty dollars on a weekend. Social service documentation showed the resident requested the money during money pass on 07/11/2026 at 10:57 AM, but was told the facility only provided two dollars on weekends because of the limited amount of money in the cash box. Staff offered to help the resident complete a money request form so the money could be received on Monday morning. Record review showed the resident’s personal funds and trust account balance was $1,648.57 on 07/13/2026. Administrative staff stated residents received two dollars during daily money pass and could request more money if needed, with a cash box available at the nurse’s station for after-hours requests. Administrative staff also stated residents should never be denied money requests if funds were available. The facility’s Resident Fund and Trust Account policy stated the trust account was for resident cash needs such as facility monthly services, haircuts, pop money, personal care items, and other approved items.
Failure to Provide Adequate Fall Interventions and Wheelchair Safety
Penalty
Summary
The facility failed to identify and implement resident-centered fall interventions for a resident with foot drop, narcolepsy, intact cognition, and a history of multiple non-injury falls. The resident’s records documented repeated falls, including falls in the shower room and while being propelled in a wheelchair by a peer, but the falls documentation did not consistently include a thorough investigation or a complete description of the resident’s fall events and environment. One progress note documented the resident reporting two falls in the shower room, while another note for the same date described a scrape on the left lower calf that staff said occurred during transfer into a van. The facility’s falls reports from 04/02/2026 through 07/12/2026 documented 19 falls that were investigated and care planned, but the reports lacked a thorough investigation for the two falls on 04/03/2026. The resident also was propelled in a wheelchair by Consultant Staff GG on 07/13/2026 without foot pedals on the wheelchair. The consultant reported he should not have pushed the resident’s wheelchair without foot pedals. Facility staff stated that after a fall, the nurse should complete risk management documentation, assess the resident, and update the care plan with a new intervention, and one administrative nurse stated there should have been an incident report and intervention for the shower falls documented in the EMR. The facility policy required the interdisciplinary team to review residents with falls weekly and for the nurse to initiate risk management documentation, complete assessment elements, determine root cause, and implement a new intervention after each fall.
Improper Storage of Respiratory Equipment
Penalty
Summary
Safe and appropriate respiratory care was not provided for a resident with COPD, pneumonia, acute chronic respiratory failure with hypoxia, and obstructive sleep apnea. The resident’s EMR showed orders for CPAP at night, oxygen as needed for shortness of breath or low oxygenation, and instructions to clean the mask, filter, and machine and to rinse and refill the humidifier daily. The resident also had intact cognition per the MDS and required supervision with some activities of daily living per the CAA. During observations, the resident’s nasal cannula was found lying directly on the floor and the CPAP mask was lying across the oxygen concentrator rather than being stored in a container. On another observation, the CPAP mask was lying on the bed and the nebulizer chamber was stored in a container with the mouthpiece resting against the wall. The resident was also observed expelling thick greenish white phlegm into the trash can next to the bed. Staff interviews showed differing descriptions of how the respiratory equipment should be stored, including placing the nasal cannula and CPAP mask in a bag or cabinet when not in use and rinsing and air drying nebulizer masks, and the facility was unable to provide a policy related to storage of respiratory equipment.
Failure to Administer Consented Pneumococcal Vaccine
Penalty
Summary
The facility failed to administer the Pneumococcal Conjugate Vaccine (PCV20) to Resident 27 after obtaining consent for the vaccine. The resident’s clinical record showed a prior Pneumovax 23 vaccination on 11/03/2020 and consent for PCV20 on 11/18/2025, but there was no documentation that the PCV20 was ever given. During interview on 07/14/2026, Administrative Nurse E stated that immunization consents or declinations were obtained from the resident or guardian on admission, that immunizations were tracked by medical records, and that if a resident consented to a vaccine, the vaccine was ordered and administered. The facility’s immunization policy stated that residents were to be offered influenza vaccine annually, pneumococcal vaccines per CDC guidelines, and other adult immunizations in accordance with current CDC recommendations, with education provided using current CDC VIS and the right to refuse.
Failure to Administer Consented Pneumococcal Vaccine
Penalty
Summary
The facility failed to administer the Pneumococcal Conjugate Vaccine (PCV20) to R27 after obtaining consent for the vaccine. R27's clinical record showed receipt of Pneumovax 23 on 11/03/2020 and consent for PCV20 on 11/18/2025, but there was no documentation that PCV20 was ever administered. During interview on 07/14/2026, the Administrative Nurse stated that immunization consents or declinations were obtained from the resident or guardian on admission, that immunizations were tracked by medical records, and that if a resident consented to a vaccine, the vaccine was ordered and given. The facility's immunization policy stated that pneumococcal vaccines were to be offered to eligible residents per CDC guidelines and that residents and responsible parties were to receive education regarding benefits, risks, and side effects using current CDC VIS.
Incomplete and Inaccurate PBJ Staffing Submission
Penalty
Summary
The facility failed to submit complete and accurate direct care staffing information to CMS through Payroll Based Journaling (PBJ) based on payroll and other verifiable and auditable data. The CMS PBJ report for Fiscal Year 2026 Quarter 1 and Quarter 2 indicated the facility triggered for excessively low weekend staffing. During interview on 07/14/2026 at 011:45 AM, Administrative Staff A stated he was responsible for sending staffing information to the corporate office, which then submitted the information to CMS, and he noted there was some difference in weekend staffing related to the number of administrative staff in the facility. He also stated he was not able to say whether the information provided to CMS was incorrect. The facility was unable to provide a policy related to PBJ, and Administrative Staff A stated the facility followed CMS guidelines related to PBJ reporting.
Failure to Maintain Sanitary Food Preparation and Storage Conditions
Penalty
Summary
Surveyors observed multiple sanitation deficiencies in the facility's kitchen during an initial tour. The hand-washing sink had a build-up of dirt and grime, and the adjacent trash can had dried food and fluid residue. Three large plastic containers used for storing dried milk, flour, and sugar were found with dust and a sticky substance on their lids. Four cutting boards had deep grooves, making them unsanitizable, and several drawers containing utensils and hot pads had food debris at the bottom. A corner cabinet used for storing sandwich bags, plastic wrap, and containers also contained food debris, and the fronts of several cabinet doors had dried-on food and liquid. Two preparation tables used for holding clean kitchenware had food debris on their lowest shelves. Further inspection revealed that two reach-in freezers and a three-door reach-in refrigerator had food debris on the bottom shelves, and several wire racks in the refrigerators had worn-off protective coatings, making them unsanitizable. The splashback behind the sink at the preparation counter had a large crack in the vinyl covering. Dietary staff confirmed these areas of concern required correction. The facility's own sanitation policy required daily cleaning of the hand-washing sink, weekly cleaning of trash barrels and drawers, and monthly cleaning of refrigerators, freezers, and food containers, but these standards were not met.
Failure to Ensure Completion of Mandatory CNA Education
Penalty
Summary
The facility failed to ensure that a Certified Nurse Aide (CNA) completed the mandatory 12 hours of education required within a 12-month period. Review of personnel and training records showed that the CNA, hired on 01/20/20, had no documented evidence of completing any of the required education in the last year. Interviews with staff confirmed that the education was expected to be completed online through Relias, and that there was a monitoring system in place to track completion, which was linked to annual staff evaluations. Despite these systems, the CNA's file lacked proof of compliance with the mandatory training requirements.
Failure to Maintain Clean and Homelike Resident Rooms
Penalty
Summary
Surveyors observed that the facility failed to maintain a clean, comfortable, and homelike environment in four out of 23 resident rooms on the south hall. Specific findings included a build-up of a black substance around the base of toilets in two rooms, unrepaired wall damage beneath a sink, and multiple areas where cove base had separated from the wall, with black substance accumulating in the gaps. Additional deficiencies included unpainted repairs on walls, missing paint on a bathroom door and window base, and confirmation from maintenance staff that these areas required repair. The facility was unable to provide a policy for housekeeping and maintenance of resident rooms. These conditions were directly observed during an environmental tour and confirmed by staff, affecting the living environment for the residents occupying these rooms.
Failure to Administer PRN Antihypertensive Medication per Physician Order
Penalty
Summary
A deficiency occurred when facility staff failed to follow physician orders for blood pressure monitoring and administration of antihypertensive medication for a resident diagnosed with hypertension. The resident had multiple active orders for blood pressure medications, including a PRN order for clonidine to be administered when systolic blood pressure (SBP) exceeded 160 mmHg. Despite several documented instances where the resident's SBP was above this threshold, the clonidine was not administered as ordered, and there were no progress notes addressing these elevated readings. The electronic medication administration record confirmed that clonidine had not been given since the start of the order. Interviews with staff revealed a lack of awareness regarding the resident's PRN blood pressure medication orders. Certified Medication Aides (CMAs) reported only notifying nurses if the SBP was 190 mmHg or higher, contrary to the physician's order. Licensed nursing staff were also unaware of the PRN order for clonidine. Administrative nursing staff acknowledged that blood pressure monitoring was not being conducted as required and verified that the medication was not administered when indicated. The facility did not provide a policy related to this process.
Failure to Implement Enhanced Barrier Precautions for Residents with Open Wounds
Penalty
Summary
Facility staff failed to implement Enhanced Barrier Precautions (EBP) for two residents with open wounds who were receiving wound care. Multiple observations revealed that there was no EBP personal protective equipment (PPE) or signage set up in or around the rooms of these residents on several occasions. Staff members, including licensed nurses, reported that they only used gloves during dressing changes and did not utilize gowns, even when treating open wounds. Staff interviews indicated inconsistent understanding and application of EBP, with some staff believing that gowns were only necessary if there was a risk of exposure to bodily fluids or if the wounds were colonized with multi-drug-resistant organisms. One resident had wounds on the abdominal folds being treated with silver alginate and an ABD pad, while another had two open areas being debrided and treated with Silvadene. Despite the facility's Infection Management Process policy stating that PPE should be available and signage posted to direct staff and visitors, these measures were not observed in practice for the affected residents. Administrative staff provided varying explanations regarding when EBP PPE should be used, further highlighting the lack of consistent implementation of infection control protocols.
Failure to Accurately Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that the posted daily nurse staffing sheets included all required and accurate information, such as the daily licensed and unlicensed staff hours and the daily census. Observations on multiple consecutive days revealed that only the first shift staffing information was filled out on the posted sheets, with the second and third shift information missing, as well as the actual hours worked. Review of staffing sheets from several dates showed that they consistently lacked the total number and actual hours worked by staff, as well as the daily census, as required by regulations. Interviews with administrative and nursing staff confirmed that the process for completing the staffing sheets involved multiple individuals, including charge nurses and administrative staff, but the required information was not being fully documented or posted. The facility was unable to provide a policy related to sufficient staffing, and the posted sheets did not meet regulatory requirements for transparency and accuracy in nurse staffing information.
Failure to Use Appropriate Transfer Equipment Leads to Resident Injury
Penalty
Summary
The facility failed to prevent the neglect of a resident, identified as R1, when staff did not utilize appropriate transfer equipment to safely meet the resident's needs. R1, who had a history of chronic obstructive pulmonary disease, congestive heart failure, osteoarthritis, morbid obesity, anxiety, and mood disorder, was admitted to the facility and required assistance with activities of daily living due to impaired balance and mobility. Despite these needs, staff attempted to transfer R1 using a gait belt that was not the appropriate size, leading to an incident where R1's legs became weak, and the staff had to lower the resident to the floor, resulting in a fracture. On the day of the incident, R1 was assisted by a licensed nurse, two certified nurse aides, and a certified medication aide. The staff attempted to stand R1 using a gait belt that was too small, and during the process, R1's legs became weak. As the staff lowered R1 to the floor, the resident's left leg buckled and rotated outward, causing a popping noise. This resulted in R1 being transported to the emergency department, where an obliquely oriented fracture through the femoral diaphysis was diagnosed. Interviews with the staff involved revealed that they were aware of R1's weakness and the need for more assistance than usual. However, they proceeded with the transfer without the appropriate equipment, such as a mechanical lift, which was later determined to be necessary for R1's safe transfer. The facility's failure to update R1's care plan and provide the necessary equipment and training contributed to the neglect and subsequent injury of the resident.
Failure to Report Resident Elopement
Penalty
Summary
The facility failed to report the elopement of a resident, identified as R2, to the State Agency as required. On the evening of 08/27/24, R2, who had a history of schizoaffective disorder, bipolar type, and other mental health issues, left the facility without staff knowledge or supervision. R2 was later found by law enforcement walking on a highway and entering a gas station approximately 0.9 miles from the facility, where he exhibited threatening behavior. The facility was notified by law enforcement, but the incident was not reported to the State Agency, placing R2 in immediate jeopardy. R2's medical records indicated a history of mental health disorders and a moderate risk for falls, but a low risk for elopement. Despite this, R2 managed to leave the facility through the smoking door without triggering any alarms. The facility's policy required that door alarms be activated at specific times, but it appears these protocols were not followed. Additionally, R2 did not have sign-out privileges, which were only granted after the incident. The facility's response to the elopement was inadequate. A licensed nurse, LN H, drove to the gas station in her personal vehicle to retrieve R2, despite not being an approved driver for the facility. During the transport back, R2 attempted to grab the steering wheel, further highlighting the risk involved. The facility's elopement policy lacked clear guidelines on reporting such incidents to the State Agency, contributing to the failure to report the elopement as required.
Resident Elopement and Inadequate Supervision
Penalty
Summary
The facility failed to protect a resident, identified as R2, from potential harm when he exited the facility unsupervised and without staff knowledge. On the evening of 08/27/24, R2 left the facility through the smoking door from the dining room at 08:48 PM. The facility was unaware of his absence until approximately 10:41 PM when law enforcement contacted them. R2 was found walking on the highway and had entered a gas station, where he threatened a store clerk and attempted to purchase cigarettes with postage stamps. This incident placed the resident in immediate jeopardy. R2's medical history included diagnoses such as schizoaffective disorder, bipolar type, communication deficit, extrapyramidal and movement disorder, anxiety disorder, and drug-induced subacute dyskinesia. Despite having a Brief Interview of Mental Status (BIMS) score of 15, indicating intact cognition, R2 exhibited disorganized thinking and verbal behaviors. He was independent in his activities of daily living but had a history of falls. The facility's records showed that R2 had a low risk for elopement and a moderate risk for falls, and his care plan did not include sign-out privileges. The facility's policy required that an approved driver transport residents in the facility van in the event of an elopement. However, a licensed nurse, LN H, drove her personal vehicle to retrieve R2 from the gas station, despite not being an approved driver. During the transport back to the facility, R2 attempted to grab the steering wheel, further endangering both himself and LN H. The facility's failure to monitor R2's whereabouts and the inappropriate response to his elopement highlighted significant lapses in supervision and adherence to established protocols.
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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 Paola
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| North Point Skilled Nursing Center | 1.2 mi | ★★★★★ | 8 | 0 |
| Louisburg Healthcare And Rehabilitation Center | 10.1 mi | ★★★★★ | 0 | 0 |
| Spring Hill Care And Rehab | 12.5 mi | ★★★★★ | 1 | 1 |
| Wellsville Manor | 15.9 mi | ★★★★★ | 23 | 0 |
| Meadowbrook Rehabilitation Hospital | 17.3 mi | ★★★★★ | 0 | 0 |
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