MedicalLodges Coffeyville: Pain Care Failures - KS
The resident, identified as R3 in the April 9 inspection report, suffered a wedge compression fracture of her second lumbar vertebra. Her care plan, revised March 31, specifically instructed staff to use alternative pain management methods including massage, aroma therapy, warm packs, and distraction.
None of it happened.
On April 7 at 10:31 AM, two certified nurse aides transferred the resident from her wheelchair to a recliner. She grimaced and made audible sounds of pain during the move. Certified Nurse Aide P told inspectors the resident "often complained of pain following a fall she had." When asked about non-drug pain treatments, he said he "was not aware of any non-pharmacologic pain interventions being utilized for the resident."
His colleague, CNA NN, knew the resident had "a lot of pain in her hips." The nurse would give pain medication, NN said, but the aide was "unaware of any non-pharmacologic pain interventions for the resident."
The resident's condition had deteriorated significantly. Her initial assessment showed moderate cognitive impairment with a Brief Interview for Mental Status score of nine. By her readmission assessment, that score had dropped to seven, indicating severe cognitive impairment.
Despite her worsening mental state, she could still communicate her suffering. The resident reported occasional pain, rating her worst pain over five days as an eight on a ten-point scale where ten represents the worst imaginable pain.
Her medication records from April 1 through April 7 documented pain levels ranging from one to seven. Staff administered physician-ordered medications including ibuprofen and hydrocodone-acetaminophen, with "effective results documented." But the drugs were only part of her prescribed treatment.
The resident's care plan explicitly called for non-pharmaceutical interventions. Her doctors had ordered both scheduled and as-needed pain medications on March 17. The facility's own care planning process identified alternative pain management as necessary.
Administrative Nurse D acknowledged the disconnect when questioned by inspectors on April 8. It was "the expectation for staff to attempt non-pharmacologic pain interventions" alongside medications, the nurse said. But the facility "did not have an actual policy for pain management" and instead "used the standard of care."
That standard apparently wasn't reaching the floor staff who worked directly with the resident. Both aides who transferred her during her obvious distress were unaware that her care plan required anything beyond medication.
The resident's medical records show she had received non-medication pain interventions during an earlier assessment period. That changed after her readmission, when documentation shows she "did not utilize non-medication pain interventions during the look-back period."
Federal inspectors found the facility failed to offer required non-pharmaceutical interventions despite clear documentation of the resident's acute pain and explicit care plan instructions. The violation affected few residents but represented a fundamental breakdown in following established care protocols.
A wedge compression fracture occurs when the front of a vertebra collapses while the back remains intact, often causing significant ongoing pain. For residents with cognitive impairment, non-drug interventions can be particularly important as they may have difficulty communicating their pain levels or understanding medication timing.
The resident's declining cognitive scores made her increasingly vulnerable. Her ability to advocate for herself diminished even as her documented pain persisted. Staff who saw her daily distress had the tools to help beyond medication but didn't know to use them.
The inspection found no evidence that supervisors had trained floor staff on the resident's specific pain management requirements or monitored whether the care plan was being followed.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Medicalodges Coffeyville On Midland from 2026-04-09 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
MEDICALODGES COFFEYVILLE ON MIDLAND in COFFEYVILLE, KS was cited for violations during a health inspection on April 9, 2026.
The resident, identified as R3 in the April 9 inspection report, suffered a wedge compression fracture of her second lumbar vertebra.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.