14 health deficiencies
Top issue: Nursing and Physician Services (3 deficiencies)
10 fire-safety deficiencies
Top issue: Egress (4 deficiencies)
Leavenworth, KS
1-star overall rating with 1-star inspections with abuse icon flag with 14 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
1503 Ohio Street, Leavenworth, KS
(913) 772-1844
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Beds
45
Certified beds
Average residents
34
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Medicalodges, Inc.
Operator or chain grouping
Approved since
1987-02-04
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
RN hours / resident day
0.50
Registered nurse staffing
LPN hours / resident day
0.72
Licensed practical nurse staffing
Aide hours / resident day
2.90
Nurse aide staffing
Weekend hours
3.70
Weekend nurse staffing
RN turnover
100%
Annual RN turnover
Total nurse turnover
87%
Annual nurse turnover
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 95.2% |
91.8%
3.4 pts better
|
93.4%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
95.5%
4.5 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
4.4%
4.4 pts better
|
3.3%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
5.6%
5.6 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 2.9% |
5.0%
2.1 pts better
|
5.4%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 28.0% |
23.2%
4.8 pts worse
|
19.6%
8.4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 8.9% |
19.8%
10.9 pts better
|
16.7%
7.8 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose ability to walk independently worsened | 25.4% |
18.4%
7 pts worse
|
16.3%
9.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 29.5% |
18.8%
10.7 pts worse
|
14.9%
14.6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.8%
1.8 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 9.0% |
3.1%
5.9 pts worse
|
1.7%
7.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 27.3% |
23.2%
4.1 pts worse
|
19.8%
7.5 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 4.0% |
4.6%
0.6 pts better
|
5.1%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 77.7% |
75.6%
2.1 pts better
|
81.7%
4 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
2.2%
2.2 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 92.6% |
73.5%
19.1 pts better
|
79.7%
12.9 pts better
|
Short Stay · 2024Q3-2025Q2 |
Survey summary
Top issue: Nursing and Physician Services (3 deficiencies)
10 fire-safety deficiencies
Top issue: Egress (4 deficiencies)
Top issue: Quality of Life and Care (10 deficiencies)
6 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Top issue: Pharmacy Service (6 deficiencies)
12 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Fire safety
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2024-12-04
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-12-04
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-12-04
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-12-04
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2024-12-04
Fire Safety
Meet other general requirements.
Corrected 2024-12-04
Fire Safety
Provide large enough exits.
Corrected 2024-12-04
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-12-04
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-12-04
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-12-04
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-06-10
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-06-10
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-06-10
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2023-06-10
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-06-10
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-06-10
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2021-12-23
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2021-12-23
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-12-23
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2021-12-23
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2021-12-23
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2021-12-23
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2021-12-23
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2021-12-23
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2021-12-23
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2021-12-23
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2021-12-23
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2021-12-23
Inspection history
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Not marked corrected
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2024-10-31
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2024-10-31
Health
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Corrected 2024-10-31
Health
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected 2024-10-31
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2024-10-31
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-10-31
Health
Provide and implement an infection prevention and control program.
Corrected 2024-10-31
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-10-31
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-10-31
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-10-31
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2024-10-31
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2024-10-31
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected 2024-10-31
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-10-20
Health
Respond appropriately to all alleged violations.
Corrected 2023-10-20
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-09-20
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2023-09-20
Health
Keep residents' personal and medical records private and confidential.
Corrected 2023-05-09
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2023-05-09
Health
Provide and implement an infection prevention and control program.
Corrected 2023-06-15
Health
Provide activities to meet all resident's needs.
Corrected 2023-05-09
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-05-09
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-05-09
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-05-09
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2023-05-09
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2023-05-09
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2023-05-09
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2023-05-09
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-05-09
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-05-09
Health
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Corrected 2023-05-09
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-06-15
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-06-15
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2023-06-15
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2023-05-09
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2023-05-09
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-05-09
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2023-05-09
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2023-05-09
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2023-05-09
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-05-09
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2023-06-15
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected 2023-05-09
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-06-15
Health
Ensure residents have reasonable access to and privacy in their use of communication methods.
Corrected 2023-05-09
Health
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected 2021-10-31
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2021-10-31
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2021-10-31
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2021-10-31
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2021-10-31
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2021-10-31
Health
Provide and implement an infection prevention and control program.
Corrected 2021-10-31
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2021-10-31
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2021-10-31
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2021-10-31
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2021-10-31
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2021-10-31
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2021-10-31
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2021-10-31
Health
Ensure that residents are free from significant medication errors.
Corrected 2021-10-31
Penalties and ownership
5% Or Greater Direct Ownership Interest · Organization
Operational/Managerial Control · Individual
Operational/Managerial Control · Organization
Operational/Managerial Control · Individual
Corporate Director · Individual
Corporate Officer · Individual
Corporate Officer · Individual
Corporate Director · Individual
Corporate Officer · Individual
Corporate Officer · Individual
Corporate Director · Individual
Corporate Officer · Individual
Corporate Director · Individual
Operational/Managerial Control · Individual
Corporate Director · Individual
Corporate Officer · Individual
Corporate Officer · Individual
Corporate Director · Individual
Corporate Officer · Individual
Corporate Officer · Individual
Corporate Officer · Individual
Corporate Director · Individual
Corporate Officer · Individual
Operational/Managerial Control · Organization
Corporate Director · Individual
Corporate Officer · Individual
Corporate Officer · Individual
Corporate Officer · Individual
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