Medicalodges Eudora

In the surveyor’s words

From the most serious findings on record at Medicalodges Eudora, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Nov 18, 2025

  The 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. […]

• Immediate jeopardy, isolatedF600Jul 16, 2025

  The 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. […]

• Actual harm, isolatedF689Jul 22, 2026

  Based 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.Findings included:- R2 admitted to the facility on [DATE], discharged to the hospital on [DATE], and readmitted to the facility on [DATE]. R2's Electronic Medical Record (EMR) documented diagnoses of a need for assistance with personal care and lack of coordination. […]

• Actual harm, isolatedF689Jun 4, 2026

  Based 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. […]

• Actual harm, isolatedF686Nov 8, 2022

  The 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. Findings included: - The electronic medical record (EMR) for R50 documented diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]