Medicalodges Eudora

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure an environment free from accident hazards when Certified Nurse Aide (CNA) O did not use a gait belt during a transfer for Resident (R) 2 resulting in a fall where R2 sustained a fracture. The facility further failed to ensure interventions to prevent falls were implemented for R14 and failed to ensure staff used a full body lift safely for R9.

Inspectors wroteBased on interview, and record review, the facility failed to provide the services of a full-time certified dietary manager for the 41 residents who resided in the facility and received their meals from the kitchen.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to maintain an effective quality assessment and assurance (QAA) program to address quality deficiencies prior to survey. Findings Included: - The facility failed to obtain informed consent from the residents or the residents' legal representatives for the installation of bedrails for Resident (R) 10, R14, R1, and R39. (Refer to F700)The facility failed to properly train staff on the proper use of the Hoyer (total body mechanical lift) lift for safe transfer of residents. R9 was transferred by Hoyer lift, and both staff members removed their hands from the lift and R9 while he was suspended in the air and transferred. (Refer to F689)The facility failed to ensure interventions were being utilized to prevent resident injury and falls. [...]

Inspectors wroteBased on interview, observation, and record review, the facility failed to obtain informed consent from the residents or the resident's legal representative for installation of bedrails for Resident (R) 10, R14, R1 and R39.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure Resident (R)4's call light was within her reach to enable her to call for staff assistance.

Inspectors wroteBased on interview, observation, and record review, the facility failed to provide services to meet professional standards of care when staff failed to ensure Resident (R)5's Electronic Medical Record (EMR) contained appropriate documentation for a schizoaffective disorder (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought) diagnosis.

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to ensure appropriate care and services to promote wound healing for Resident (R) 36 when staff failed to use the correct physician's treatment order.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure adequate services for respiratory care when staff failed to provide Resident (R) 44 with as needed (PRN) breathing treatments as ordered for shortness of air (SOA)/shortness of breath (SOB).

Inspectors wroteBased on observation, record review and interviews, the facility failed to ensure Resident (R)33 remained free from a significant medication error when staff failed to follow the physician prescribed administration schedule for R33's Carbidopa-Levodopa (medication used to control tremors shaking associated with Parkinson's disease).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the posted nurse staffing contained the required information when staff failed to include the resident census or posted an inaccurate census.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure Certified Nurse Aide (CNA) M used a gait belt and two-person assist during toileting and toileting hygiene for Resident (R) 1 to prevent accidents. On 04/17/2026 at approximately 01:15 PM, CNA M assisted R1 with toileting. When R1 stood up in front of the toilet for CNA M to clean bowel movement off of her, R1 stated she needed to sit down and proceeded to sit back down onto the edge of the toilet. R1 slipped off the toilet edge and onto the floor. R1's right leg bent backwards at the knee with her ankle positioned at the height of her upper body. CNA M called for help, and Licensed Nurse (LN) G responded. The facility called for assistance from Emergency Medical Services (EMS) to assist R1 off the floor, which they were able to do after they provided medication. [...]

Inspectors wroteThe facility reported a census of 38 residents. The sample included three residents, reviewed for elopement/elopement risk. Based on observation, interview, and record review, the facility failed to ensure staff provided adequate supervision for cognitively impaired Resident (R) 1, who was at moderate risk for elopement. On 08/25/25 at approximately 12:50 PM, Administrative Staff B opened the facility door to allow R1 and R3 outside to sit on the patio. Administrative Staff B told Licensed Nurse (LN) G R1 was outside, seated in her electric wheelchair. At 02:10 PM, Emergency Medical Services (EMS) alerted the facility that they responded to a 911 call and found R1 on the ground approximately one-half mile from the facility. R1 hit a curb in her electric wheelchair, fell, and hit her head. The facility staff were unaware R1 had left the facility until they received the EMS call. [...]

Inspectors wroteThe facility identified a census of 45 residents, with three residents reviewed for abuse. Based on record review, observations, and interviews, the facility failed to prevent the mental abuse of cognitively impaired and dependent residents, Residents (R) 2, R3, and R4. In May 2025, Hospitality Aide P took demeaning and humiliating photos of the residents in compromising positions, without their consent, knowledge, or permission. Hospitality Aide P kept the images on her personal cell phone and later texted them to at least one other staff member. It is unknown if Hospitality Aide P distributed the images beyond this incident. This deficient practice violated the rights of R2, R3, and R4 and placed the residents in immediate jeopardy, based on reasonable person concept, for the negative psychosocial impact of fear, humiliation, privacy violation, and dehumanization.

Inspectors wroteThe facility identified a census of 49 residents. Based on observation, record review, and interview, the facility failed to provide Registered Nurse (RN) coverage eight consecutive hours a day, seven days a week. This placed all residents who resided in the facility at risk of lack of assessment and inappropriate care.

Inspectors wroteThe facility identified a census of 49 residents. The sample included 14 residents and five Certified Nurse Aides (CNA) were reviewed for yearly performance evaluations and the associated in-service training. Based on record review and interview, the facility failed to ensure five of the five CNA staff reviewed had yearly performance evaluations completed. This placed the residents at risk for inadequate care.

Inspectors wroteThe facility identified a census of 49 residents and one kitchen. Based on interviews and record reviews, the facility failed to provide the services of a full-time certified dietary manager for the 49 residents who resided in the facility and received their meals from the kitchen. This placed the residents at risk for inadequate nutrition.

Inspectors wroteThe facility identified a census of 49 residents. Based on interviews, and record review the facility failed to submit accurate staffing information to the federal regulatory agency through Payroll Based Journaling (PBJ) when the facility failed to submit accurate registered nurse (RN) coverage hours. This placed the residents at risk for unidentified and ongoing inadequate staff.

Inspectors wroteThe facility had a census of 49 residents. Five Certified Nurse Aides (CNAs) were sampled for required in-service training. Based on record review and interview, the facility failed to ensure three of the five CNA staff reviewed had the required 12 hours of in-service education. This placed the residents at risk for decreased quality of life and/or inadequate care.

Inspectors wroteThe facility identified a census of 49 residents. The sample included 14 residents with five residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported the need for a physician-documented rationale for non-approved Center for Medicare and Medicaid Services (CMS) indications for the use of antipsychotic medications (class of medications used to treat major mental conditions which cause a break from reality) for Resident (R) 35, R20, R19, and R27. This deficient practice placed these residents at risk for adverse medication effects and medication errors.

Inspectors wroteThe facility identified a census of 49 residents. The sample included 14 residents with five residents reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 27, R19, R20, and R35 had an approved Centers for Medicaid and Medicare (CMS) indication or the required physician documentation for antipsychotic medications(class of medications used to treat major mental conditions which cause a break from reality). The facility failed to ensure a documented physician rationale which included the multiple unsuccessful attempts for nonpharmacological symptom management and risk versus benefits for continued use or gradual dose reduction (GDR). This placed the affected residents at risk for unnecessary psychotropic medication and possible adverse side effects.

Inspectors wroteThe facility identified a census of 49 residents. The facility identified one resident on transmission-based precautions (TBP-infection control procedures to limit the transmission of infectious agents). Based on record review, observations, and interviews, the facility failed to post clear signage for the TBP room and failed to implement Enhanced Barrier Precautions (EBP-infection control interventions designed to reduce transmission of resistant organisms which employs targeted gown and glove use during high contact cares) for all residents requiring EBP. These deficient practices placed the residents at risk for infectious diseases. Findings Included: - An initial walkthrough of the facility was completed on 08/12/24 at 07:17 AM with the following observations noted: [...]

Inspectors wroteThe facility identified a census of 49 residents. The sample included 14 residents with one resident reviewed for dignity. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 4's urinary catheter (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid) drainage bag was placed in a privacy bag. This deficient practice placed R4 at risk for impaired dignity and decreased psychosocial well-being.

Inspectors wroteThe facility identified a census of 49 residents. The sample included 14 residents. One resident was sampled for reasonable accommodations of resident needs and preferences. Based on observation, record review, and interview, the facility failed to ensure Resident (R)24's call light was within her reach. This deficient practice left R24 at risk for unmet care needs due to the inability to call for staff assistance.

Inspectors wroteThe facility had a census of 48 residents. The sample included 14 residents, with one resident reviewed for physical restraint. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 42 was free of physical restraints when staff placed R42 in a recliner, and raised the footrest though R42 was unable to lower the footrest on her own. This placed the resident in a supine position in the recliner and impeded R42's freedom of movement and mobility. This deficient practice placed R42 at risk for impaired mobility, impaired resident rights and autonomy, and increased risk for restraint-related accidents. Findings Included: [...]

Inspectors wroteThe facility identified a census of 49 residents. The sample included 14 residents with one resident sampled for hospitalization Based on record review and interview the facility failed to provide a written notice of transfer as soon as practicable to Resident (R) 50 or their representative for their facility-initiated transfers. This deficient practice had the risk of miscommunication between the facility and resident/family and possible missed opportunity for healthcare service for R50.

Inspectors wroteThe facility identified a census of 49 residents. The sample included 14 residents with one resident sampled for hospitalization. Based on observations, record review, and interview the facility failed to provide a bed hold notice to Resident (R) 50 or their representative when R50 transferred to the hospital. This deficient practice placed R50 at risk for impaired ability to return to the facility or the same room.

Inspectors wroteThe facility identified a census of 49 residents. The sample included 14 residents sampled for care plan revision. Based on observation, record review, and interview, the facility failed to ensure staff revised Resident (R)151's Care Plan with staff direction for safe transfers. The facility failed to ensure staff revised R8's plan of care with interventions after a fall. This placed R151 and R8 at risk for impaired care due to uncommunicated care needs.

Inspectors wroteThe facility identified a census of 49 residents. The sample included 14 residents with three residents reviewed for positioning. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 151 had interventions in place to avoid a further decrease in range of motion (ROM). This placed the resident at risk for decreased mobility and impaired quality of life.

Inspectors wroteThe facility identified a census of 49 residents. The sample included 14 residents with five residents reviewed for accidents. Based on observation, record review, and interviews, the facility failed to ensure meaningful interventions were implemented for Resident (R) 8 after falls. This deficient practice placed R8 at risk for future falls and possible injuries.

Inspectors wrote- R24's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of Parkinson's disease (a slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness), depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, and emptiness), tardive dyskinesia (abnormal condition characterized by involuntary repetitive movements of the muscles of the face, limbs and trunk), schizophrenia (mental disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought), muscle weakness, and dysphagia (swallowing difficulty). [...]

Inspectors wroteThe facility identified a census of 49 residents. The sample included 14 residents with one person reviewed for side rails. Based on observation, record review, and interviews, the facility failed to attempt the use of alternative measures prior to installing Resident (R) 24's side rail and the facility further failed to complete a side rail safety assessment that acknowledged the presence of a low air loss mattress and the associated risks, prior to installation of the side rails for R24. This deficient practice placed R24 at risk of injury due to unidentified risks from the use of side rails.

Inspectors wroteThe facility identified a census of 49 residents. The sample included 14 residents with one resident reviewed for hospice services. Based on observation, record review, and interviews, the facility failed to ensure a communication process was implemented, which included how the communication would be documented between the facility and the hospice provider, and a failed to provide a description of the services, medication, and equipment provided to Resident (R) 20 by hospice. This deficient practice created a risk of missed or delayed services and inadequate end-of-life care for R20.

Inspectors wroteThe facility identified a census of 49 residents. The sample included 14 residents with five residents reviewed for immunizations. Based on observation, record review, and interviews, the facility failed to provide Resident (R) 19 with the Pneumococcal Conjugate Vaccine (PCV20- vaccination for bacterial lung infections) as consented. This placed the resident at increased risk for complications related to pneumonia.

Inspectors wroteThe facility identified a census of 49 residents. Based on observation, record review, and interviews, the facility failed to maintain the posted daily nurse staffing data for the required 18 months. The facility additionally failed to list the daily census on the provided daily staffing documentation.

Inspectors wroteThe facility identified a census of 56 residents. The sample included 16 residents. Based on observation, record review, and interview the facility failed to implement, immediate interventions which included offloading actions such as heel boots of heel floating when Resident (R) 50 developed a stage two pressure injury (pressure injury which expands into deeper layers of the skin. It can look like a scrape (abrasion), blister, or a shallow crater in the skin) As a result of the deficient practice R50's original blister (stage two pressure injury) worsened to a full thickness wound which became infected and required acute management and care.

Inspectors wroteThe facility identified a census of 56 residents. Based on observation, record review, and interview, the facility failed to provide Registered Nurse (RN) coverage eight consecutive hours a day, seven days a week. This placed all residents who resided in the facility at risk of lack of assessment and inappropriate care.

Inspectors wroteThe facility identified a census of 56 residents. Based on record review, and interviews, the facility failed to ensure a staff person was a staff person designated as the Infection Preventionist, who was responsible for the facility's Infection Prevention and Control Program, completed the specialized training in infection prevention and control. This deficient practice placed all residents at risk for lack of identification, tracking/trending, and treatment of infections.

Inspectors wroteThe facility had a census of 56 residents. The sample included 16 residents. Based on observation, record review and interview the facility failed to secure chemicals in a safe, locked area, and out of reach of the 12 cognitively impaired independently mobile residents. The facility additionally failed to implement R11's anti-rollback device for her wheelchair. This deficient practice placed the affected residents at risk for accidents. Findings Included: On 11/02/22 at 07:08AM an inspection of an unlocked small sink room next to the rear oxygen tank room revealed an open one-gallon bottle of bleach. The label on the bleach read keep out of reach of children, hazardous to humans can cause eye irritation, harmful if swallowed. The sink room had no lock to secure the chemical product. [...]

Inspectors wroteThe facility identified a census of 56 residents. The facility had one main kitchen. Based on observation, record review and interview the facility failed to ensure that room trays of food were kept at a safe temperature for consumption by residents.

Inspectors wroteThe facility identified a census of 69 residents. Based of observations, record review, and interviews, the facility failed to ensure staff were following safe and sanitary infection control practices related to isolation, respiratory equipment, urinary catheters, and personal protective equipment (PPE). This deficient practice placed the residents at risk for preventable infections and illnesses. Findings Included: - On 11/02/22 at 07:02 AM upon entering the facility 2 staff were observed not wearing face coverings in the front hallway. On 11/02/22 at 07:05 AM an inspection of the 200 hallway revealed isolation supplies outside of R3's room, but no signage displayed to indicate if she was on isolation or signage to direct visitors to see nurse before entering room. [...]

Inspectors wroteThe facility identified a census of 56 residents. The sample included 16 residents which five residents reviewed for immunizations. Based on record review, and interviews, the facility failed to obtain pneumococcal (pneumonia infection that inflames air sacs in one or both lungs which may fill with fluid) vaccination consents, declinations or administration information for Residents (R) 50, R25 and R4 and influenza (highly contagious viral infection that attacks the lungs, nose, and throat and can be deadly in high-risk groups) vaccination consents, declinations or administration information for R36 and R4. This deficient practice placed residents at increased risk for influenza, pneumonia, and related complications.

Inspectors wroteThe facility identified a census of 56 residents. The sample included 16 residents. Based on observation, record review, and interviews, the facility failed to ensure foot pedals were provided for Resident (R) 31's broda chair (specialized wheelchair with the ability to tilt and recline) to prevent her feet from dragging on the floor. This deficient practice placed R31 vulnerable for possible injuries.

Inspectors wroteThe facility identified a census of 56 residents. The sample included 16 residents with one reviewed for notification of changes. Based on observation, record review, and interviews, the facility failed to notify R11's resident representative and her physician about a skin tear on her upper arm. This deficient practice placed R11 at risk for ineffective treatment and delayed wound care. Findings Included: -The Medical Diagnosis section within R11's Electronic Medical Records (EMR) included diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), major depressive disorder (major mood disorder), cognitive communicative deficit, muscle weakness, hypertension (high blood pressure), and edema (swelling resulting from an excessive accumulation of fluid in the body tissues). [...]

Inspectors wroteThe facility identified a census of 56 residents. The sample included 16 residents with one reviewed for transmission of resident assessments. Based on observation, record review, and interviews, The facility failed to electronically transmit R34's Significant Change of Status Minimum Data Set (MDS) within 14 days after completion. This deficient practice placed R34 at risk for delayed treatment and services. Findings Included: [...]

Inspectors wroteThe facility identified a census of 56 residents. The sample included 16 residents. Based on observation, record review and interview the facility failed to revise a comprehensive person-centered care plan for Resident (R)50 that included interventions to avoid the development of a pressure wound. This deficient practice placed R50 at risk for further skin breakdown and injury.

Inspectors wroteThe facility identified a census of 56 residents. The sample included 16 residents with two reviewed for comprehensive care plans. Based on observation, record review, and interviews, the facility failed to provide individualized care plan interventions for R25's bowel and bladder incontinence. This deficient practice placed the resident at risk for complications related to incontinence and increased incontinence -The Medical Diagnosis section within R25's Electronic Medical Records (EMR) included diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), constipation, major depressive disorder (major mood disorder), impulse disorder, dysphagia (swallowing difficulty), and chronic kidney disease. [...]

Inspectors wroteThe facility identified a census of 56 residents. The sample included 16 residents. Based on observation, record review, and interviews, the facility failed to ensure staff provided bathing for one of three residents, who required extensive assistance from staff to complete the care. This deficient practice placed Resident (R) 3 at risk for potential skin breakdown and/or skin complications from not maintaining good personal hygiene and bathing practices.

Inspectors wroteThe facility identified a census of 56 residents. The sample included 16 residents with four residents reviewed for quality of care. Based on observations, record reviews, and interviews, the facility failed to follow implement preventative skin interventions for Residents (R)11 and R34. This deficient practice placed the residents at risk preventable skin injuries. Findings Included: - The Medical Diagnosis section within R11's Electronic Medical Records (EMR) included diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), major depressive disorder (major mood disorder), cognitive communicative deficit, muscle weakness, hypertension (high blood pressure), and edema (swelling resulting from an excessive accumulation of fluid in the body tissues). [...]

Inspectors wroteThe facility identified a census of 56 residents. The sample included 16 residents, with one resident reviewed for range of motion (ROM- the full movement potential of a joint, usually its range of flexion and extension)/mobility. Based on observation, record review, and interviews, the facility failed to ensure staff applied Resident (R) 19's splint and brace as ordered by the physician, which placed R19 at risk for further decrease in ROM.

Inspectors wroteThe facility identified a census of 56 residents. The sample included 16 residents with four residents reviewed for bowel and bladder management. Based on observations, record reviews, and interviews, the facility failed to implement individualized toileting programs for Residents (R)25 and R33. The facility failed to maintain sanitary indwelling urinary catheter care for R34. This deficient practice placed the residents at risk for complications related urinary tract infections. Findings Included: -The Medical Diagnosis section within R25's Electronic Medical Records (EMR) included diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), constipation, major depressive disorder (major mood disorder), impulse disorder, dysphagia (swallowing difficulty), and chronic kidney disease. [...]

Inspectors wroteThe facility identified a census of 56 residents. The sample included 16 residents with two residents reviewed for respiratory care. Based on observations, record reviews, and interviews, the facility failed ensure consistent and hygienic respiratory care and services for Resident (R)11. This deficient practice placed R11 at risk for complications due to respiratory therapy. Findings Included: -The Medical Diagnosis section within R11's Electronic Medical Records (EMR) included diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), major depressive disorder (major mood disorder), cognitive communicative deficit, muscle weakness, hypertension (high blood pressure), and edema (swelling resulting from an excessive accumulation of fluid in the body tissues). [...]

Inspectors wroteThe facility identified a census of 56 residents. The sample included 16 residents with one reviewed for competent nursing staff. Based on observation, record review, and interviews, the facility failed to ensure an accurate assessment of R11's skin tear was completed by a licensed nurse. This deficient practice placed R11 at risk for ineffective treatment and delayed wound care. Findings Included: - The Medical Diagnosis section within R11's Electronic Medical Records (EMR) included diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), major depressive disorder (major mood disorder), cognitive communicative deficit, muscle weakness, hypertension (high blood pressure), and edema (swelling resulting from an excessive accumulation of fluid in the body tissues). [...]

Inspectors wroteThe facility identified a census of 56 residents. The sample included 16 residents. Five residents were reviewed for medication review. Based on interview, record review, and interview the facility failed to ensure that resident (R)36's prescribed antidepressant (a class of medications used to treat mood disorders and relieve symptoms of depression) medication Prozac and R18's salicylic acid (a medication used to dissolve skin flakes and scales) were available for administration. This placed R36 and R18 at risk for adverse side effects and ineffective treatment.

Inspectors wroteThe facility reported a census of 56 resident. Based of observations, record review, and interviews, the facility failed to ensure safe storage and handling of the resident's medications. This deficient practice placed the residents at risk for unnecessary medication and administration errors. Findings Included: - On 11/02/22 at 07:10AM upon entrance to the facility Certified Medication Aid (CMA) T was observed counting medication cards at the medication cart located next to the front nurse's station. CMA T quickly left the cart and went into medication room next to the nurse's station. Inspection of the medication cart revealed that CMA T had left the unsupervised medication cart unlocked. Ten of the resident's medication cards sat on top of the unsecured cart while two residents walked past it in the hallway. [...]

Inspectors wroteThe facility identified a census of 56 residents. The sample included 16 residents. Based on observation, record review, and interviews, the facility failed to ensure a plate guard was provided at meals for Resident (R) 19, which placed her at risk of loss of independence with eating which could cause impaired psychosocial wellbeing.

Inspectors wroteThe facility identified a census of 56 residents. The sample included 16 residents. Based on observation, record review, and interviews, the facility failed to retain the daily posted nursing staffing data for the 18 months as required.