Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
MEDICALODGES LEAVENWORTH
LEAVENWORTH, KS · 45 certified beds · Last Life Safety survey September 25, 2024
CMS Certification Number 175162 · first certified February 1987
Ownership
Operated by MEDICALODGES, INC. · For profit - Corporation
No change of ownership on CMS record since January 1, 2016, when the records begin.
Position within KS
28 citations — more than 51% of the 296 certified nursing homes in KS. Compared within KS rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 10 citations; the earlier surveys in the window averaged 9. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
Well past the typical window (May 2026 to July 2026), and past the point by which nine in ten KS facilities have been surveyed. This facility’s last Life Safety survey was September 2024. Facilities in KS are typically surveyed 20–22 months after the last one (median 21), measured over 298 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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5 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Physical environment (health survey)
6 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 28 Life Safety citations above. The Physical Environment Index
- F-0880 Provide and implement an infection prevention and control program.
- F-0584 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.
- F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
How that compares
Compared with the median facility in KS, and nationally. Surveyors differ markedly between states, so the KS figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 28 |
| Median facility in KS | 27 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| September 16, 2021 | 12 |
| April 10, 2023 | 6 |
| September 25, 2024 | 10 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 3 | 2024-09-25 |
| K-0363 | Install corridor and hallway doors that block smoke. | 2 | 2023-04-10 |
| K-0511 | Have properly installed electrical wiring and gas equipment. | 2 | 2024-09-25 |
| K-0222 | 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. | 2 | 2023-04-10 |
| K-0712 | Have simulated fire drills held at unexpected times. | 2 | 2024-09-25 |
| K-0914 | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | 2 | 2024-09-25 |
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | 2 | 2023-04-10 |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | 1 | 2023-04-10 |
What the citations cover
- Smoke Deficiencies 9
- Egress Deficiencies 8
- Gas, Vacuum, and Electrical Systems Deficiencies 5
- Services Deficiencies 3
- Other 3
| Category | Citations |
|---|---|
| Smoke Deficiencies | 9 |
| Egress Deficiencies | 8 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 5 |
| Services Deficiencies | 3 |
| Miscellaneous Deficiencies | 3 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
September 25, 2024 — 10 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0200 | Meet other general requirements. | Deficient, Provider has date of correction (December 4, 2024) |
| K-0223 | Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Deficient, Provider has date of correction (December 4, 2024) |
| K-0231 | Provide large enough exits. | Deficient, Provider has date of correction (December 4, 2024) |
| K-0293 | Have properly located and lighted "Exit" signs. | Deficient, Provider has date of correction (December 4, 2024) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (December 4, 2024) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (December 4, 2024) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (December 4, 2024) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (December 4, 2024) |
| K-0914 | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Deficient, Provider has date of correction (December 4, 2024) |
| K-0923 | Have proper medical gas storage and administration areas. | Deficient, Provider has date of correction (December 4, 2024) |
April 10, 2023 — 6 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0222 | 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. | Deficient, Provider has date of correction (June 10, 2023) |
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | Deficient, Provider has date of correction (June 10, 2023) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (June 10, 2023) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (June 10, 2023) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Deficient, Provider has date of correction (June 10, 2023) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Deficient, Provider has date of correction (June 10, 2023) |
September 16, 2021 — 12 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0222 | 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. | Deficient, Provider has date of correction (December 23, 2021) |
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | Deficient, Provider has date of correction (December 23, 2021) |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (December 23, 2021) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (December 23, 2021) |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | Deficient, Provider has date of correction (December 23, 2021) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (December 23, 2021) |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | Deficient, Provider has date of correction (December 23, 2021) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (December 23, 2021) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (December 23, 2021) |
| K-0914 | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Deficient, Provider has date of correction (December 23, 2021) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (December 23, 2021) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (December 23, 2021) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.