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 Minneola District Hospital Ltcu during CMS and state inspections, most recent first.
A resident with severe cognitive impairment was served hot pureed foods without temperature checks, leading to discomfort and immediate jeopardy. The dietary staff did not verify food temperatures before sending them to nursing staff, and the facility's policy to assess food safety before feeding was not followed.
A resident with dementia and severely impaired cognition was hospitalized for dehydration due to the facility's failure to provide sufficient fluid intake. Despite care plan instructions and family requests, the resident's water was often out of reach, and staff did not consistently offer or encourage hydration. The facility's records showed multiple instances of inadequate fluid intake, leading to the resident's hospitalization for dehydration and a UTI.
A medication cart was found unlocked and unattended in a hallway, containing various medications, posing a risk to nine cognitively impaired, independently mobile residents. Staff interviews confirmed that the cart should have been locked when not in sight, but the facility lacked a specific policy for cart control when staff are absent.
The facility failed to maintain sanitary conditions in food storage, preparation, and service, risking foodborne illness for all residents. A trash can in the food prep area had a flip-top lid, and a dietary aide was observed pushing trash with a gloved hand and continuing food prep without changing gloves, violating the facility's hygiene policy.
The facility failed to maintain proper infection control during linen delivery. Clean laundry was transported with a cart cover improperly draped, exposing linens to potential contamination. Staff interviews and facility policy confirmed that all sides of the cart should be covered during transport.
The facility's laundry service area was found to be deficient in maintaining a safe and sanitary environment. Observations included uncovered soiled linen bins, broken and missing floor tiles in both soiled and clean areas, and an abraded doorway exposing bare wood. The facility also lacked a policy for maintenance and housekeeping in the laundry.
A resident was transferred to the shower room with her buttocks exposed, compromising her dignity. Additionally, a container in the dining room was labeled 'bibs only, no trash,' visible to all, affecting residents' dignity. Staff interviews revealed a lack of awareness and adherence to dignity protocols.
The facility failed to ensure accurate documentation and easy identification of residents' code statuses, leading to deficiencies in managing advanced directives. Several residents' records lacked physical DNR forms and necessary signatures, causing inconsistencies in their documented wishes. Staff interviews revealed confusion and difficulty in locating code status information during emergencies, highlighting gaps in training and policy implementation.
A discrepancy in the count of Lyrica pills for a resident was discovered during a narcotics count, revealing a failure in the facility's system for accurate accounting of controlled medications. The previous shift's CMA did not record the administration of Lyrica, and the oncoming CMA failed to perform an actual count, leading to an incorrect record. The facility's policy contained contradictory information regarding count signature requirements.
The facility failed to ensure timely responses to pharmacist recommendations for medication regimen reviews and gradual dose reductions for several residents, leading to potential unnecessary medication administration. Delays in physician responses ranged from 17 to 109 days, and the facility's policy lacked guidance on timely follow-up. Observations noted residents with severe cognitive impairments and potential overmedication, while staff were unclear on expected timelines for physician responses.
The facility did not ensure that daily nurse staffing sheets included accurate information, such as the facility name and total hours worked by staff. Observations showed missing details on the staffing sheet near the nurse's station, and a review of past sheets revealed similar issues. Administrative Staff C confirmed the inaccuracies and was unaware of the regulatory requirements.
Failure to Ensure Safe Food Temperatures for Resident
Penalty
Summary
The facility failed to ensure that a dependent resident, identified as R2, remained free from accident hazards and harm when staff fed him pureed foods without checking the temperature to ensure they were safe to eat. R2, who had severe cognitive impairment and was dependent on staff for assistance with eating, was served hot pureed soup and a pureed grilled cheese sandwich. The soup had been heated to 196 degrees Fahrenheit, and the sandwich to 150 degrees Fahrenheit, without the temperature being checked before serving. This resulted in R2 grimacing and pulling his head back, indicating discomfort from the hot food. The dietary staff heated the pureed foods in the microwave and placed them in insulated containers on a steam table, but did not check the temperatures before sending them to the nursing staff. The facility's food temperature logs showed that all meals lacked documentation of temperatures obtained prior to serving, with hot food items consistently above 165 degrees Fahrenheit. Dietary staff were unaware of any limitations on hot food temperatures to prevent burns, and nursing staff were expected to check food temperatures by holding their hand over the food before serving. The facility's policy required that all food be assessed for safety before assisting a resident with feeding, but this was not followed. The failure to check the temperature of the pureed foods before serving placed R2 in immediate jeopardy, as confirmed by the administrative staff who acknowledged the non-verbal signs of pain exhibited by R2 when served the hot food.
Removal Plan
- Education and policies reviewed by the Care Plan Team
- Held a QAPI meeting to discuss issues identified and plan of correction with Medical Director, CEO, COO, LTC Director, DON, ADON, Floor Charge Nurse, CSSD and Dietary Manager
- Education provided to ensure nursing staff and dietary staff know the correct procedure for monitoring food temperatures prior to serving pureed food to a resident
- All staff will be notified of changes in procedure and given verbal education and instruction on serving pureed food to a resident prior to returning to work. Signatures will be collected to signify understanding
- Dietary will track pureed food for temperature prior to leaving the kitchen and will not leave the kitchen window unless between the range of 145-165 degrees Fahrenheit. A log will be created to allow staff to log temperature prior to serving and include section for comments if the food did not leave the kitchen for a specific reason. The Dietary Manager will check documentation for compliance
- Audit will be performed during mealtimes, and randomly
- Results of Audits findings will be reviewed at QAPI meetings
Failure to Maintain Resident Hydration
Penalty
Summary
The facility failed to provide sufficient fluid intake to maintain proper hydration and health for Resident 6, who was diagnosed with dementia and amnesia, and had severely impaired cognition. The resident was dependent on staff for all activities of daily living, including eating, and required supervision and assistance. Despite the family's requests and care plan instructions to encourage fluid intake and keep water accessible, the facility did not consistently ensure that the resident had access to fluids. Observations revealed that the resident's water was often out of reach, and staff did not offer or encourage hydration during certain periods. The facility's records showed that Resident 6 had multiple instances of fluid intake below 1500 cc per day, which is below the facility's hydration policy requirements. The resident was hospitalized for dehydration and a urinary tract infection, which was attributed to insufficient fluid intake. Interviews with administrative nurses confirmed that the task to offer fluids was not consistently documented or completed, contributing to the resident's hospitalization. The facility's failure to adhere to its hydration policy resulted in actual harm to the resident.
Unsecured Medication Cart Poses Risk to Residents
Penalty
Summary
The facility failed to ensure the secure storage of medications, as observed on a specific date when a medication cart was found unlocked and unattended in a hallway between the dining and commons areas. This cart contained oral, topical, and inhaled medications. The incident was confirmed by a Certified Medication Aide (CMA) who acknowledged that the cart should be locked when not attended or within her line of sight. Further interviews with a Licensed Nurse (LN) and an Administrative Nurse confirmed that the facility's practice requires medication carts to be locked when out of the responsible person's line of sight, including when their back is turned. The deficiency placed nine cognitively impaired, independently mobile residents at risk, as identified by the Administrative Nurse. Despite the facility having a Controlled Medications Policy and Procedure, it failed to provide a specific policy outlining the process for medication cart control when staff are not present. This oversight in policy and practice led to the unsecured medication cart being accessible in a common area, posing a potential risk to residents.
Sanitation Lapses in Food Preparation
Penalty
Summary
The facility failed to maintain sanitary conditions in food storage, preparation, and service, which placed all residents at risk for foodborne illness. During an observation, a trash can located at the hand washing sink in the food preparation area was found to have a flip-top lid instead of a foot-operated lid, which could lead to contamination. Additionally, a dietary aide was observed pushing down trash into the trash can with a gloved hand and then resuming food preparation without changing gloves. This action violated the facility's Food Preparation and Service Policy, which mandates that gloves must be changed between tasks to prevent contamination. The policy also prohibits bare hand contact with food and requires gloves to be worn when handling food directly. These lapses in hygiene and sanitary practices contributed to the deficiency.
Infection Control Deficiency in Linen Delivery
Penalty
Summary
The facility failed to maintain a comprehensive infection control program related to the delivery of clean linens. During an observation, it was noted that laundry personnel transported clean resident laundry in a cart with one of the side covers draped over the top, exposing the clean laundry to potential contamination. Interviews with Laundry Staff Z, Laundry Supervisor W, and Administrative Staff H confirmed that the linen cart should have all sides covered during transport and when unattended in the hallway. The facility's policy, dated 01/15/25, also stated that the sides of the linen cart should be closed while in motion and at each destination to prevent contamination. This oversight had the potential to lead to contamination of clean linens during delivery.
Deficiencies in Laundry Service Area
Penalty
Summary
The facility failed to maintain a safe, functional, and sanitary environment in the laundry service area, as observed during a tour with Administrative Staff H and Laundry/Housekeeping Staff W. The deficiencies included two uncovered soiled linen bins with a sock hanging off the side, indicating improper containment of soiled items. Additionally, the walkway tiled floor from the soiled linen area to the clean area was not sanitizable due to two broken and missing floor tiles. Similarly, the floor in the clean linen processing area had two missing tiles beside the washing machine, compromising its sanitizability. Furthermore, the egress from the clean linen room to the hallway entrance/exit doorway had multiple abrasions exposing bare wood, which was also not sanitizable. The facility lacked a policy related to maintenance and housekeeping in the laundry, contributing to these environmental concerns.
Dignity Issues During Resident Transfer and Dining
Penalty
Summary
The facility failed to protect the dignity of a resident, identified as R10, during a transfer from her room to the shower room. An observation revealed that R10 was transported in a shower chair covered with a white sheet from her neck to her knees, leaving her buttocks exposed. This exposure was visible to anyone in the area, which compromised the resident's dignity. Interviews with staff, including a Certified Medication Aide (CMA) and a Licensed Nurse (LN), indicated that residents should be fully covered during such transfers, but there was a lack of awareness that R10's buttocks were exposed. Additionally, the facility did not honor the dignity of residents in the dining room by labeling a container for soiled clothing protectors as 'bibs only, no trash.' This label was visible to all residents, staff, and visitors, potentially affecting the residents' dignity and psychosocial well-being. An administrative staff member acknowledged that the term 'clothing protector' should be used instead of 'bib' and confirmed that the labeling would be corrected. The facility's Resident Rights policy emphasizes treating each resident with dignity, which was not upheld in these instances.
Deficiencies in Advanced Directives Documentation
Penalty
Summary
The facility failed to ensure that each resident's code status was accurately documented and easily identifiable, leading to deficiencies in the management of advanced directives for several residents. Specifically, the facility's admission packet lacked prompts or forms for residents or their representatives to fill out regarding advanced directives. For Resident 17, the electronic health record (EHR) indicated a Do Not Resuscitate (DNR) status, but there was no physical DNR form or physician order to confirm this status. The care plan inconsistently documented the resident's code status, and the physical chart lacked a signed DNR form. Similarly, Resident 3's EHR and physical chart were missing a physical DNR form and lacked necessary signatures on advanced directives. The physician's orders included a DNR, but the documentation was incomplete, with missing signatures from the resident, a witness, and a physician. Resident 14's records also showed inconsistencies, with the EHR indicating a DNR status but lacking a physical DNR form and necessary signatures on advanced directives. Resident 171's records documented a full code status with special instructions for Do Not Intubate (DNI), but there was no DNI form available. Interviews with staff revealed confusion and difficulty in locating and verifying residents' code statuses during emergencies. Certified Nurse Aides and Certified Medication Aides indicated that they would rely on the EHR or ask other staff members if unsure about a resident's code status. Administrative Nurse C confirmed the difficulty in identifying orders and acknowledged that new and agency staff lacked training on locating code status information. The facility's policies on CPR and advanced directives were not effectively implemented, resulting in missing or incomplete documentation for several residents.
Controlled Medication Count Discrepancy
Penalty
Summary
The facility failed to ensure an effective system for the accurate accounting and reconciliation of controlled medications, specifically Lyrica pills for a resident. During a medication cart narcotics count, a discrepancy was found where the count sheet displayed 39 pills, but the hard count was 38 pills. This discrepancy was not caught during the count by the Certified Medication Aide (CMA) K, who documented that the night nurse had not taken anything from the cart. CMA K took the cart at 6:20 AM to start the morning medication pass but did not count the pills in the bottle, leading to the incorrect recording of the Lyrica count. The facility's investigation revealed that the previous shift's CMA S had given the resident their evening Lyrica and failed to record it on the count sheet. Subsequently, CMA K did not perform an actual count of the Lyrica and recorded the wrong number during her morning counts. The facility's policy for controlled medications, which was revised recently, contained contradicting information regarding count signature requirements, contributing to the failure in maintaining an accurate accounting system for controlled substances.
Delayed Response to Pharmacist Recommendations in LTC Facility
Penalty
Summary
The facility failed to ensure a timely response to the pharmacist's identified and reported irregularities and recommendations for several residents, leading to potential administration of unnecessary medications. For Resident 8, the pharmacist recommended gradual dose reductions (GDR) for medications such as Duloxetine and Risperidone, but the physician's responses were delayed by 20 days and 21 days, respectively. Additionally, the facility took 10 days to transcribe the physician's response for Risperidone, further delaying the process. The facility's policy on Drug Regimen Review lacked guidance on timely follow-up, contributing to these delays. Resident 15 also experienced delays in the response to pharmacist recommendations for GDR of medications like Fluoxetine and Abilify. The physician's responses were delayed by 17 days for both medications. Observations noted the resident was sedate and had a flat affect, indicating potential overmedication. The facility's process for handling pharmacist recommendations was not clearly defined, and staff were unsure of the expected timeline for physician responses. For Resident 17, the facility failed to ensure timely physician response to GDR requests for medications such as Klonopin and Cymbalta, with delays of 109 days and 44 days, respectively. Similarly, Resident 6's medication regimen review was not adequately addressed, with no response to a GDR recommendation for Trazodone and missing documentation for a monthly review. The facility's policy did not address timely follow-up, and no performance improvement plan was in place to address these deficiencies.
Inaccurate Nurse Staffing Information Posted
Penalty
Summary
The facility failed to ensure that the posted daily nurse staffing sheets included accurate and identifiable information, such as the facility name and the total number of actual hours worked per shift by licensed and unlicensed staff. During an observation, it was noted that the daily staffing sheet near the nurse's station lacked this critical information. A review of the staffing sheets from a previous date revealed that most sheets were missing the total number and actual hours worked per shift. During an interview, Administrative Staff C confirmed the inaccuracies and admitted to being unaware of the regulatory requirements for the staffing sheets. The facility's policy on Sufficient Staffing mandates that leadership provide adequate personnel on a 24-hour basis and that staffing and census information be posted prominently for accessibility to residents and visitors.
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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 Minneola
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Fowler Residential Care | 10.7 mi | ★★★★★ | 0 | 0 |
| Sunporch Of Dodge City | 20.4 mi | ★★★★★ | 1 | 0 |
| Meade District Hosp Ltcu Dba Lone Tree Retirement | 20.6 mi | ★★★★★ | 22 | 0 |
| Hill Top House | 21.6 mi | ★★★★★ | 0 | 0 |
| Kansas Soldiers Home | 21.8 mi | ★★★★★ | 5 | 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.