Catholic Care Center, Inc
Inspection history, citations, penalties and survey trends for this long-term care facility in Bel Aire, Kansas.
- Location
- 6700 E 45th Street North, Bel Aire, Kansas 67226
- CMS Provider Number
- 175410
- Inspections on file
- 23
- Latest survey
- November 18, 2025
- Citations (last 12 mo.)
- 1 (1 serious)
Citation history
Health deficiencies cited at Catholic Care Center, Inc during CMS and state inspections, most recent first.
A resident with a neurogenic bladder had a physician's order for a 20 French suprapubic catheter, but staff inserted a 12 French catheter instead. When staff attempted to correct the error, they were unable to insert the correct size and had to reinsert the smaller catheter. The resident was later seen by a urologist who placed a 16 French catheter. This failure to follow physician orders and facility policy resulted in a deficiency in catheter care.
Staff did not consistently follow Enhanced Barrier Precautions during high-contact care, such as suprapubic catheter care, and failed to disinfect a Hoyer lift between resident uses. These actions were not in accordance with facility policy and placed residents at risk for infection.
The facility failed to maintain a safe environment and implement care-planned fall interventions for residents, leading to deficiencies in care. One resident's bed was placed in a high position against their care plan, increasing fall risk. Another resident's bed was also left high, lacking guidance on bed height. Additionally, two residents did not have required safety measures, such as a Dycem and a fall mat, in place, putting them at risk for falls.
The facility failed to maintain sanitary conditions for residents' medical equipment and did not implement adequate hand hygiene. A CMA used a blood pressure cuff on multiple residents without sanitizing it, and nasal cannulas for three residents were improperly stored. A CPAP mask was also stored incorrectly. Staff interviews revealed inconsistencies in cleaning and storage practices, which did not align with the facility's infection prevention policy, risking infectious disease transmission.
A facility with 147 residents failed to ensure agency CNAs received required resident rights training. Credentialing files for CNAs MM, NN, and OO lacked evidence of this training. Administrative Nurse D assumed the agency provided necessary training, but only covered dementia, infection control, abuse, falls, and change in condition upon staff's first shift. The facility lacked a policy on required training for nurse aides.
A facility failed to maintain the dignity of two residents during meals. One resident, with severe cognitive impairment, was left with a clothing protector on after a meal, while another resident, also with cognitive impairment, was given a drink by a CNA standing over him without interaction. The facility's policy requires residents to be treated with dignity, which was not upheld in these instances.
A facility failed to notify a resident's guardian about the addition of psychotropic medication, Ativan gel, to the resident's treatment plan. The resident, with severely impaired cognition and multiple health conditions, was dependent on staff for daily activities. Despite procedures requiring nurses to inform guardians of medication changes, the guardian was not notified, and the facility lacked evidence of a notification policy.
A resident with end-stage renal disease and a gastrostomy had an inaccurately coded MDS, missing documentation of enteral feeding. The resident's EMR showed a physician's order for enteral feeding, which was not reflected in the MDS, placing the resident at risk for unmet care needs. Staff interviews revealed the dietician's oversight, and the facility lacked a policy for MDS coding.
A resident with a history of falls and dementia, requiring substantial assistance for transfers, was injured during a transfer when a CNA used the resident's arms instead of a Hoyer lift, as prescribed in the care plan. The CNA attempted the transfer without a gait belt, leading to bruising on the resident's arms. The facility's policy on ADLs was not followed, resulting in physical harm to the resident.
The facility failed to provide adequate pressure ulcer prevention and care for two residents, leading to increased risk of ulcer development. One resident, with multiple medical conditions, was not consistently offloaded as required, while another resident, with severe cognitive impairment, lacked a pressure-reducing cushion in their wheelchair. Staff did not adhere to care plans and physician orders, contributing to the deficiency.
A facility failed to ensure a resident's supplemental oxygen was turned on, risking respiratory complications. The resident had a history of respiratory issues and was observed with an inactive oxygen concentrator. Additionally, another resident's CPAP mask was improperly stored, increasing infection risk. Staff interviews revealed procedural inconsistencies, and the facility lacked a policy for respiratory equipment storage.
A facility failed to adequately monitor and document a resident's dialysis access site, specifically the arteriovenous fistula (AVF), which is essential for hemodialysis. Despite the care plan and physician orders requiring daily assessment for thrill, bruit, and signs of infection, the facility only conducted assessments on dialysis days. This lack of daily monitoring and documentation placed the resident at risk for adverse outcomes related to dialysis.
A facility failed to provide trauma-informed care for two residents with PTSD, R75 and R107. R75's care plan lacked individualized interventions to prevent re-traumatization, and staff were unaware of her trauma history. R107's care plan did not address specific triggers, and there was no trauma-informed care assessment conducted. Staff were not informed about residents with PTSD, indicating a lack of communication and training. These deficiencies placed the residents at risk for decreased psychosocial well-being and ineffective treatment.
A resident with Alzheimer's and severe cognitive impairment did not receive adequate dementia-related behavioral services, as her care plan lacked specific strategies to address her aggressive behaviors and potential triggers. Despite interventions like CBD gummies and one-to-one supervision, the facility failed to identify underlying causes for her behaviors, compromising her well-being.
A facility failed to act on a Consultant Pharmacist's recommendations for a resident prescribed Ativan without a stop date. The resident, with diagnoses of anxiety, depression, and dementia, was observed asleep in a wheelchair without food or drinks. The facility's policy required documentation of pharmacist recommendations, but this was not followed, risking adverse effects and unnecessary medication use.
A resident with a history of hypertension and other conditions was administered antihypertensive medications despite having a systolic blood pressure below the physician-ordered threshold. The facility's policy required staff to verify medication orders and parameters, which was not followed, leading to the resident's admission to an acute care facility due to low blood pressure.
The facility failed to ensure that PRN psychotropic medications for two residents had a 14-day stop date or specified duration, risking unnecessary medication administration. One resident with anxiety, depression, and dementia was prescribed Ativan without a stop date, while another with multiple diagnoses was prescribed Lorazepam gel without a stop date. Staff were unsure of the duration for PRN orders, indicating non-compliance with facility policy.
A facility failed to ensure proper collaboration with a hospice provider for a resident, risking inadequate end-of-life care. The resident's care plan lacked directions for staff on hospice collaboration, supplies, and visit schedules. Staff interviews confirmed the absence of necessary hospice information in the care plan, despite facility policy requiring such coordination.
Failure to Use Correct Catheter Size During Suprapubic Catheter Care
Penalty
Summary
Staff failed to provide appropriate catheter care for a resident with a diagnosis of neuromuscular dysfunction of the bladder, who had a physician's order for a 20 French suprapubic catheter. The resident's care plan directed staff to change the catheter monthly and as needed. However, staff inserted a 12 French catheter instead of the ordered 20 French size. When an attempt was made to replace the incorrect catheter with the correct size, the nurse was unable to insert the 20 French catheter after several attempts and ultimately reinserted the 12 French catheter. The incident was documented in the resident's progress notes, and the resident was later seen by a urologist who placed a 16 French catheter. The facility's policy required staff to use the proper catheter size as ordered and to report any complications. Interviews with administrative nurses confirmed the expectation that staff use the correct catheter size. The error in catheter size selection and the subsequent difficulty in correcting it constituted a failure to follow physician orders and facility policy, resulting in a deficiency in catheter care for the resident.
Failure to Follow Enhanced Barrier Precautions and Equipment Disinfection
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program as required by policy and regulatory standards. Specifically, a licensed nurse provided suprapubic catheter care to a resident using gloves but did not don a gown, as required under Enhanced Barrier Precautions (EBP) for high-contact care activities involving indwelling medical devices. Additionally, another licensed nurse assisted a certified nurse aide in transferring a resident using a Hoyer lift and subsequently placed the lift in a hallway cubby without disinfecting it between resident uses, contrary to facility policy and CDC recommendations. Interviews with administrative nursing staff confirmed that staff were expected to follow EBP protocols and clean equipment such as Hoyer lifts between each resident use. The facility's own policies, dated October 2024 and 2018, outlined the need for EBP during high-contact care and for cleaning and disinfecting resident-care equipment according to CDC and OSHA standards. These lapses in following established infection control procedures were observed during routine care activities and placed residents at risk for infection.
Failure to Maintain Safe Environment and Implement Fall Interventions
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for several residents, leading to deficiencies in care. One resident, with severe cognitive impairment and a history of falls, was found to have her bed intentionally placed in a high position by staff, contrary to her care plan which required the bed to be in a low position to prevent falls. This action was taken to prevent the resident from getting back into bed without assistance, but it increased her risk of falling due to her impulsive behavior and cognitive deficits. Another resident, who was dependent on staff for transfers and had moderately impaired cognition, was also found with their bed in a high position. The care plan did not provide guidance on bed height, but staff interviews confirmed that the bed should not be left in a high position due to the resident's fall risk. This oversight placed the resident at risk for fall-related injuries. Additionally, the facility failed to implement care-planned fall interventions for two other residents. One resident, who required a Dycem in their wheelchair to prevent falls, was observed multiple times without it in place. Another resident, who was at risk for falls, did not have a fall mat beside their bed as required by their care plan. These failures to follow care plans and ensure safety measures were in place put the residents at risk for preventable falls and injuries.
Inadequate Infection Control Practices
Penalty
Summary
The facility failed to maintain sanitary conditions for several residents' medical equipment and did not implement adequate hand hygiene practices. Specifically, a Certified Medication Aide (CMA) used a blood pressure cuff on multiple residents without sanitizing it between uses and did not perform hand hygiene before handling the equipment. Additionally, nasal cannulas for three residents were not stored in a sanitary manner when not in use, with instances of them being placed on the floor, over wheelchairs, or hanging over bed rails without proper containment. A CPAP mask for another resident was improperly stored directly on the CPAP machine or bedside table, contrary to the facility's infection prevention and control policy. Interviews with staff revealed inconsistencies in the cleaning and storage practices for CPAP masks and nasal cannulas. While some staff members stated that CPAP masks should be cleaned with soap and water and hung to dry, others mentioned using disinfectant wipes and storing them in plastic bags. The facility's infection prevention and control policy, dated 2019, emphasized the importance of maintaining a safe and sanitary environment to prevent the transmission of communicable diseases. However, the observed practices did not align with these guidelines, placing residents at risk for infectious diseases.
Deficiency in Resident Rights Training for Agency CNAs
Penalty
Summary
The facility, with a census of 147 residents, failed to ensure that direct care staff received the required training on resident rights. This deficiency was identified through a review of the credentialing files for agency CNAs MM, NN, and OO, which lacked evidence of completed resident rights training. Administrative Nurse D, responsible for reviewing nursing staff information from the agency staffing company, assumed that the agency ensured the nurse aides had the necessary training. However, upon the staff's first shift, only training on dementia, infection control, abuse, falls, and change in condition was provided, omitting resident rights. The facility did not have a policy regarding the required training for nurse aides, which contributed to the oversight.
Failure to Maintain Resident Dignity During Meals
Penalty
Summary
The facility failed to uphold the dignity and respect of Resident 75 by not removing her clothing protector after a meal. Resident 75, who has severe cognitive impairment due to conditions such as anxiety, depression, and dementia, was observed in the dining room with a clothing protector still attached, even though she was not eating or drinking. Staff members, including a CNA and a licensed nurse, acknowledged that leaving a clothing protector on a resident after a meal is a dignity concern, and the facility's policy emphasizes treating residents with dignity and respect. Another incident involved Resident 13, who has severe cognitive impairment and multiple health conditions, including schizoaffective disorder, epilepsy, and cerebral palsy. During a meal, a CNA was observed standing over Resident 13 while giving him a drink, without engaging in any interaction. This action was contrary to the facility's policy, which requires staff to be at eye level and engage with residents during assistance. Both a licensed nurse and the CNA involved confirmed that staff should sit next to residents and engage with them during meals. The facility's Quality of Life-Dignity policy, revised in 2020, mandates that residents be treated in a manner that promotes their well-being and self-esteem. The failure to adhere to this policy in the cases of Residents 75 and 13 resulted in a deficiency report, highlighting the risk of negative psychosocial outcomes and decreased dignity for the residents involved.
Failure to Notify Guardian of Medication Changes
Penalty
Summary
The facility failed to notify the guardian of Resident 13 about changes related to the addition of psychotropic medications, specifically Ativan gel, to the resident's treatment plan. The resident, who has a history of schizoaffective disorder, epilepsy, depression, diabetes mellitus, hypertension, intellectual disabilities, anxiety, cerebral palsy, sleep apnea, adult failure to thrive, and edema, was documented to have severely impaired cognition and was dependent on staff for activities of daily living. The resident's care plan included monitoring for side effects and effectiveness of the antianxiety medication every shift, but there was no evidence in the clinical record that the guardian was informed of the new medication order. Interviews with the nursing staff revealed that it was the nurses' responsibility to inform guardians and resident representatives of any medication changes and to document this communication in the electronic medical record. However, the guardian of Resident 13 stated that she had not been informed about the addition of any medication or changes to the medication regimen. The facility's administrative nurse confirmed that the charge nurse should notify the resident's guardian of any changes, and unit nurse managers were responsible for running daily reports of new orders and following up with guardians. Despite these procedures, the facility did not provide evidence of a policy for notification of changes, leading to the deficiency in communication with the resident's guardian.
Inaccurate MDS Coding for Resident with Enteral Feeding
Penalty
Summary
The facility failed to ensure that a significant change Minimum Data Set (MDS) for a resident with end-stage renal disease and a gastrostomy was accurately coded. The resident's MDS section K0520, which pertains to Nutritional Approaches, lacked documentation of the feeding tube and the percentage of calories and amount of fluids provided through it. This oversight was identified during a review of the resident's Electronic Medical Record (EMR), which showed a physician's order for enteral feeding that was not reflected in the MDS. The resident was on a physician-prescribed weight gain regimen and was at risk for dehydration, as noted in the Nutritional Care Area Assessment (CAA). The deficiency was further highlighted when the resident, who was able to eat regular meals but required enteral feeding due to weight loss and dialysis therapy, was observed in the dining room. Interviews with facility staff revealed that the dietician did not mark the MDS for enteral feeding, and the administrative nurse acknowledged the need for a modification to the MDS. The facility did not provide a policy regarding the MDS when requested, indicating a lapse in ensuring accurate coding as required by the Resident Assessment Instrument (RAI) Manual.
Improper Transfer Technique Leads to Resident Injury
Penalty
Summary
The facility failed to ensure appropriate and safe assistance with activities of daily living (ADL) for a resident, identified as R93, during a transfer, which resulted in bruises on both of the resident's arms. R93 had a medical history that included repeated falls, hypertension, blindness in one eye, and dementia, and was on hospice services. The resident required substantial to maximal assistance for bed-to-chair transfers and had a care plan that directed the use of a Hoyer lift for such transfers. However, during an incident, a Certified Nurse Aide (CNA) transferred R93 using the resident's upper arms instead of the prescribed method, leading to bruising. The incident occurred when the CNA attempted to transfer R93 to a wheelchair that was not properly prepared, as it was full of bed pads. Despite the resident's refusal to use a gait belt, the CNA proceeded with the transfer, resulting in the resident becoming stiff and uncooperative. The CNA, along with another aide, attempted to complete the transfer by holding the resident's arms, which led to the bruising. The resident expressed concern about the transfer process and reported that the CNA seemed frustrated during the incident. The facility's policy on ADLs emphasizes providing care to maintain or improve residents' abilities, but in this case, the staff did not adhere to the care plan or the policy. The CNA involved was unaware of the proper procedure to follow when a resident refuses a gait belt, which should have included stopping the transfer and notifying a charge nurse. This lack of adherence to the care plan and policy resulted in the resident experiencing physical harm and distress.
Failure in Pressure Ulcer Prevention and Care for Two Residents
Penalty
Summary
The facility failed to ensure proper pressure ulcer prevention and care for two residents, R22 and R13, which increased their risk for pressure ulcer development and delayed healing. R22, who had multiple medical conditions including diabetes mellitus, hemiparesis following a stroke, and a deep tissue injury on the right lateral foot, was observed on multiple occasions with his heels resting directly on the mattress, contrary to physician orders to keep his heels offloaded. Despite having boots and a pillow available for offloading, R22 was not consistently provided with these interventions, and there was no documentation of refusal from R22. Staff members, including CNAs and nurses, were not adequately informed or did not follow through with the care plan requirements for offloading R22's heels. R13, who had severe cognitive impairment and multiple diagnoses including schizoaffective disorder, epilepsy, and cerebral palsy, was observed sitting in his wheelchair without a pressure-reducing cushion on several occasions. The care plan for R13 required the use of a pressure-reducing device in his wheelchair to prevent pressure ulcers. However, staff, including therapy and nursing personnel, failed to ensure that R13 had the necessary cushion in place. The therapy director acknowledged that therapy staff should have noticed the absence of the cushion, and the responsibility was shared between therapy and nursing staff. The facility's policy on pressure ulcers and skin breakdown required nursing staff and practitioners to assess and document risk factors for pressure ulcers and to implement medical interventions as ordered. However, the facility did not adhere to these policies, as evidenced by the lack of proper offloading for R22 and the absence of a pressure-reducing cushion for R13. This oversight in following care plans and physician orders contributed to the increased risk of pressure ulcer development for both residents.
Deficiencies in Respiratory Care and Equipment Storage
Penalty
Summary
The facility failed to ensure that a resident's physician-ordered supplemental oxygen supply was turned on, which placed the resident at risk of respiratory complications and possible infection. The resident, who had a history of respiratory failure, dysphagia, aspiration pneumonia, dementia, and COPD with hypoxia, was observed sitting in a wheelchair with a nasal cannula connected to an oxygen concentrator that was not turned on. Despite the resident's care plan directing staff to maintain oxygen saturation above 90%, the concentrator was found off, and staff were notified of this oversight. Additionally, the facility did not store another resident's CPAP mask in a sanitary manner, increasing the risk of respiratory infection and complications. The resident, who had a history of cerebrovascular accident and sleep apnea, was observed with her CPAP mask and tubing placed directly on the CPAP machine on the bedside table. The care plan required the CPAP mask to be cleaned with soap and water and hung to dry, but staff were found to be using disinfectant wipes and storing the mask in a plastic bag instead. Interviews with staff revealed inconsistencies in the procedures followed for both residents. Certified Nurse Aides and Licensed Nurses acknowledged the need for continuous oxygen for the first resident and proper cleaning and storage of the CPAP mask for the second resident. However, the facility lacked a policy related to the storage of respiratory equipment, contributing to the deficiencies observed.
Inadequate Monitoring of Dialysis Access Site
Penalty
Summary
The facility failed to provide adequate monitoring and documentation of a resident's dialysis access site, specifically the arteriovenous fistula (AVF), which is crucial for hemodialysis. The resident, identified as R80, had a diagnosis of end-stage renal disease and required dialysis three times a week. Despite the care plan and physician orders indicating the need for daily assessment of the AVF for thrill and bruit, as well as monitoring for signs of infection, the facility's records showed a lack of daily documentation and assessment. Observations and interviews with staff revealed that assessments were only conducted on dialysis days, contrary to the expected daily checks. The facility's policy required staff to monitor the dialysis access site for signs of infection, bleeding, and the status of the dressing, and to document these assessments in the electronic medical record (EMR). However, the clinical record for R80 lacked evidence of daily assessments, placing the resident at risk for adverse outcomes and physical complications related to dialysis. Interviews with nursing staff and administrative personnel confirmed the deficiency in monitoring and documentation practices, highlighting a failure to adhere to the facility's dialysis policy.
Failure in Trauma-Informed Care for Residents with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care for two residents, R75 and R107, who had histories of trauma and PTSD. R75's electronic medical record documented diagnoses of anxiety, depression, and dementia, with a severely impaired cognition score. Despite the care plan indicating that staff should recognize her specific triggers to avoid re-traumatization, there were no individualized interventions in place. Observations showed R75 unattended in the dining room, and staff members, including a CNA and a licensed nurse, were unaware of her trauma history or potential triggers. R107, diagnosed with PTSD and schizoaffective disorder, also lacked a trauma-informed care assessment. Her care plan included engaging her in simple activities but did not address specific triggers to prevent re-traumatization. Staff, including a CNA and an agency licensed nurse, were not aware of any residents with PTSD, indicating a lack of communication and training regarding trauma-informed care. The facility's policy required assessments for trauma-informed care at admission and during significant changes, but this was not followed for R107. The facility's failure to identify trauma-based triggers and implement individualized interventions for R75 and R107 placed them at risk for decreased psychosocial well-being and ineffective treatment. The facility's trauma-informed care policy emphasized culturally sensitive and person-centered care, yet the lack of adherence to this policy resulted in deficiencies in the care provided to these residents.
Inadequate Dementia Care for Resident
Penalty
Summary
The facility failed to provide adequate dementia-related behavioral services for a resident, identified as R30, which compromised her highest practicable level of well-being. R30 had a medical history of Alzheimer's disease, seizures, epilepsy, and insomnia, and was noted to have severe cognitive impairment with a BIMS score of five. Her care plan indicated she required substantial assistance with activities of daily living and had aggressive behaviors towards others, often refusing care. Despite these needs, the care plan lacked specific strategies to address potential triggers or causes for her behaviors, particularly around meal services, and did not include individualized non-pharmacological interventions to prevent repeated behaviors. R30's behavioral episodes were documented in her EMR, including incidents of verbal and physical aggression towards other residents and staff. These episodes occurred in various settings, such as the dining room and other residents' rooms, and were sometimes managed with CBD gummies and one-to-one supervision. However, the facility's care plan did not adequately identify or address the underlying causes of her behaviors, nor did it provide effective strategies for redirecting her during episodes of confusion and agitation. Interviews with facility staff revealed that while some interventions, such as walks and one-to-one time, were used to manage R30's behaviors, there was a lack of consistent identification of triggers and causative factors. The facility's Behavioral Health Services policy emphasized the need for individualized interventions, but the absence of a specific dementia care policy and the incomplete care plan for R30 highlighted deficiencies in the facility's approach to managing her condition. This oversight placed R30 at risk for decreased quality of life, isolation, and impaired dignity.
Failure to Address Pharmacist Recommendations for Antianxiety Medication
Penalty
Summary
The facility failed to ensure that the Consultant Pharmacist's (CP) recommendations were acknowledged and acted upon for a resident identified as R75. The resident's electronic medical record documented diagnoses of anxiety, depression, and dementia, with a severely impaired cognition score. The resident was prescribed Ativan, an antianxiety medication, without a stop date, and the CP's monthly medication review recommended a rationale for continued use and a specific stop date. However, there was no documentation that the physician reviewed or addressed these recommendations. Observations revealed that R75 was found asleep in a high-back wheelchair in the dining room, not positioned at a table, and without food or drinks present. Administrative Nurse D confirmed the absence of a physician's response to the CP's recommendations and described the process of handling medication regimen reviews, which included delivering them to physicians and unit managers. The facility's policy required that CP recommendations be documented and maintained as part of the permanent medical record, but this was not adhered to, placing the resident at risk of adverse side effects and unnecessary medication use.
Failure to Follow Antihypertensive Medication Parameters
Penalty
Summary
The facility failed to adhere to physician-ordered parameters for administering antihypertensive medications to a resident, identified as R303, which led to the administration of unnecessary medications. R303 had a medical history that included acute respiratory failure, atherosclerotic heart disease, atrial fibrillation, hypertension, and chronic kidney disease. The resident's care plan required monitoring and reporting changes related to his antihypertensive medications to his medical provider. Despite this, on November 9, 2024, the resident's systolic blood pressure was recorded at 99 mmHg, below the threshold of 110 mmHg, yet the medications amlodipine, lisinopril, and terazosin were administered contrary to the physician's orders. The facility's medication administration policy required staff to verify medication orders and parameters before administration, which was not followed in this instance. Interviews with staff revealed that the Medication Administration Report (MAR) should have flagged the low blood pressure to prevent medication administration, and staff were expected to check vital signs before giving antihypertensive medications. The failure to adhere to these protocols resulted in the resident being admitted to an acute care facility due to low blood pressure, highlighting a significant lapse in medication management and monitoring within the facility.
Failure to Ensure PRN Psychotropic Medications Have Stop Dates
Penalty
Summary
The facility failed to ensure that PRN psychotropic medications for two residents, R75 and R13, had a 14-day stop date or a specified duration with supporting physician documentation. This oversight placed the residents at risk for unnecessary medication administration and potential adverse side effects. The facility's policy, revised in 2016, required that antipsychotic medications be prescribed at the lowest possible dosage for the shortest period and be subject to gradual dose reduction and re-review. Resident 75's electronic medical record documented diagnoses of anxiety, depression, and dementia, with a severely impaired cognition score. The resident was prescribed Ativan as needed for anxiety or restlessness, but the order lacked a stop date or a physician-documented rationale for the extended PRN use. Observations noted the resident asleep in a wheelchair without proper positioning or access to food and drinks, indicating potential overmedication. Resident 13's medical record included diagnoses of schizoaffective disorder, epilepsy, depression, and other conditions, with a severely impaired cognition score. The resident was prescribed Lorazepam gel for agitation or anxiety, but the order also lacked a stop date. The facility's staff, including licensed nurses and administrative nurses, were unsure of the duration for which PRN antianxiety medication orders could be active, indicating a lack of adherence to the facility's policy and procedures for psychotropic medication use.
Failure to Collaborate with Hospice Services
Penalty
Summary
The facility failed to ensure proper collaboration of care between a resident's hospice provider and the facility, which placed the resident at risk of inadequate end-of-life care. The resident, who had a history of repeated falls, hypertension, blindness in one eye, and dementia, was on hospice services. The resident's care plan, however, lacked specific directions for staff on how to collaborate with hospice, what supplies the hospice service provided, or when hospice staff would make visits. This lack of information was confirmed through interviews with facility staff, who indicated that while hospice books were available, the care plan did not contain the necessary hospice information. The facility's policy required coordination with hospice representatives to ensure the resident's needs were met 24 hours a day, and that care plans included the most recent hospice plan of care. Despite this, the care plan for the resident did not reflect the hospice services provided or how to contact them, as confirmed by the administrative nurse. This oversight in the care plan documentation and lack of collaboration with hospice services led to the deficiency identified by the surveyors.
Latest citations in Kansas
Surveyors found that the facility failed to maintain sanitary food storage, handling, and dishwashing practices in the kitchen. Clean dishes were stored upright instead of inverted, and numerous food items in coolers, freezer, pantry, and spice racks were undated, missing the year, had unreadable dates, or showed visible mold, while some bags and containers were left open or unsealed. A dietary staff member handled ready-to-eat foods such as bread and butter with bare hands and repeatedly washed hands with water only, without soap or sanitizer, while preparing pureed meals for a resident. The low-heat dish machine repeatedly operated below the facility’s stated minimum wash temperature, as documented on the temperature log. These practices were inconsistent with the facility’s own food storage policy and staff’s stated expectations for glove use, labeling, sealing of food, dish storage, and dishwashing temperatures.
The facility did not employ a full-time Certified Dietary Manager (CDM) as required by its own Nutritional Services Policy, despite serving meals to 31 residents. A dietary staff member without CDM credentials was observed overseeing meal preparation, and both this staff member and an administrative nurse confirmed that the staff member was not certified, although enrolled in CDM classes. The policy specified that a CDM must oversee key functions such as menu planning, diet and diet manual with nutritional evaluations, office procedures for notifying the RD of new elders, food production, and food service, but no certified individual was fulfilling these responsibilities.
Surveyors found that the facility failed to follow professional standards for food storage and temperature monitoring. A freezer had significant ice buildup, and a refrigerator contained unlabeled, undated sliced cheese. Temperature logs for multiple freezers and refrigerators were incomplete over several days, despite policy requiring routine monitoring and documentation. The ice machine area contained extraneous items, including a plastic lid, a metal object on the floor, and a cup on the drain. In dry storage, several open food items, including pasta, noodles, gelatin, and pancake mix, were undated, unlabeled, or unsealed. Dietary staff confirmed these conditions, and the Dietary Manager later described expectations that all food be labeled, dated, and properly sealed per facility policy.
Surveyors found that staff did not consistently follow EBP, hand hygiene, and clean laundry handling practices. During tracheostomy care for a resident, a nurse wore gloves and a mask but did not don a gown or change gloves before placing clean gauze and the trach cannula. In a separate case, after completing wound care for another resident, the same nurse manipulated a suprapubic catheter tubing while still holding wound supplies and then left the room without performing hand hygiene. Additionally, a housekeeping/laundry staff member removed residents’ personal items from a covered cart and carried them over the shoulder between halls without keeping the items covered. These actions did not follow facility policies requiring targeted gown and glove use for high-contact care, proper hand hygiene around invasive devices and dressings, and keeping laundry carts covered between rooms.
A resident with hemiparesis, chronic osteomyelitis, and intervertebral disc disorder with radiculopathy experienced a fall in his room, was found on the floor near a heater with pain and bruising, and was later confirmed by mobile X-ray to have a nondisplaced fracture of the left superior pubic ramus. Despite this, the subsequent quarterly MDS documented no falls since the prior assessment and did not code the event as a fall with major injury, even though the care plan and progress notes described the fall and resulting fracture. An administrative nurse later acknowledged that the falls section of the MDS had been coded in error, contrary to facility policy and RAI manual requirements for accurate resident assessment.
A resident with severe morbid obesity, vascular dementia, anxiety, and a history of falls, but intact cognition per BIMS, was repeatedly assisted in a wheelchair by staff without foot pedals in place. On multiple observed occasions, staff pushed and turned the resident in the wheelchair while the resident held his feet off the floor and a sock was seen dragging on the floor. Interviews showed staff uncertainty and inconsistency regarding the requirement for foot pedals when assisting the resident, despite the resident’s documented fall risk and a facility falls policy requiring interventions to reduce fall risk.
A resident with Alzheimer’s disease, CKD, BPH, obstructive uropathy, and urinary retention had a suprapubic catheter that staff repeatedly secured incorrectly. During catheter care, two nurses cleaned the abdominal insertion site but attached the Stat-lock to the resident’s thigh, anchoring the tubing to the leg instead of the abdomen. Nursing leadership stated they expected leg anchoring and noted the catheter policy did not specify Stat-lock placement, even though the facility’s suprapubic catheter competency checklist explicitly directed that the tubing be secured to the abdomen.
A resident with dementia, severe cognitive impairment, and depression experienced unplanned weight loss after the RD documented a slow weight-loss trend and recommended house supplement shakes TID with added calories to meals. The facility entered and carried out the supplement order only once daily, and staff confirmed the resident received a shake only on second shift. Weight documentation showed a large, unverified increase followed by a re-weigh that demonstrated a 3.16% loss over a short period, and nursing staff did not promptly recognize or recheck the significant weight discrepancy. The RD was not informed that her TID recommendation had been effectively reduced to once daily, and the facility’s own weight-loss prevention processes were not followed.
A resident with chronic respiratory failure, a tracheostomy, and oxygen therapy orders did not have an Ambu bag or emergency tracheostomy kit readily available at the bedside, despite care plan directives for respiratory care, suctioning, and emergency response if the tracheostomy tube came out. Surveyors observed on multiple occasions that only oxygen and suction were present in the room, while the Ambu bag and emergency supplies were stored on a covered cart in the hallway under a Hoyer lift, requiring movement of equipment before use. Staff, including CNAs, an LN, and an administrative nurse, confirmed that emergency tracheostomy supplies were kept in the hallway or medication room and not at the bedside, and that they were instructed to call 911 rather than attempt reinsertion of the tracheostomy tube, even though the facility’s respiratory care policy required services in accordance with professional standards and the resident’s care plan.
A resident with diabetes, heart failure, muscle weakness, severe cognitive impairment, incontinence, and limited mobility was identified as at risk for pressure ulcers, with care plans calling for turning/repositioning, use of a pressure-reducing device, and extensive staff assistance for ADLs. Despite these documented risks and interventions, the resident, who preferred to remain in a recliner or wheelchair and became less mobile after a foot fracture requiring a walking boot, developed a facility-acquired Stage 2 pressure ulcer on the buttocks. Wound assessments showed the ulcer’s presence and progression over time, indicating that timely and effective preventive measures were not implemented in accordance with the facility’s wound assessment and prevention policy.
Unsanitary Food Storage, Handling, and Dishwashing Practices in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to maintain sanitary conditions for food storage and preparation in the kitchen. During an initial kitchen tour, they observed multiple clean containers and plates on the drying rack not inverted, leaving eating surfaces exposed. Numerous food items in the kitchen cooler, walk-in cooler, freezer, pantry, and spice rack were either undated, missing the year, had unreadable dates, or were past labeled use-by dates. Examples included cheese and ham slices with only month and day, multiple large containers of sauces, dressings, olives, cherries with visible black mold on the rim and lid, parmesan cheese, syrups, soy sauce, wing sauce, and green beans all lacking complete or legible dating. Additional findings included rusted and peeling cooler racks, open and unsealed bags of frozen foods and pantry items, and a rice bin with a handwritten prep date missing the year. Further observations showed improper food handling and hand hygiene practices by dietary staff. One dietary staff member handled ready-to-eat foods, including butter and bread for toast, with bare hands and then placed the toast on a tray for a resident. On another occasion, a partially wrapped package of cheese slices in the cooler was found without any date. The same dietary staff member was observed washing hands under running water without using soap or sanitizer on three separate occasions while pureeing food for lunch. The facility did not provide a hand hygiene policy specific to dietary staff when requested. Surveyors also reviewed the operation of the low-heat Ecolab dishwasher and its temperature logs. At the time of observation, the wash temperature was 102°F, and the April temperature log showed multiple days with wash temperatures below the documented minimum of 120°F at which the supervisor should be notified. Administrative and dietary staff later confirmed that gloves should be worn when handling ready-to-eat foods, all stored food should be sealed and labeled with month, day, and year, dishes should be inverted, and the dishwasher wash cycle should be at least 120°F. The facility’s existing Food Storage policy required staff to label all food items with the name and date opened or use-by date and to discard food past expiration, but survey findings showed these practices were not consistently followed in the kitchen.
Lack of Certified Dietary Manager Overseeing Food and Nutrition Services
Penalty
Summary
The facility failed to employ a full-time certified dietary manager (CDM) to oversee food and nutrition services for 31 residents receiving meals from the facility kitchen. On one observed noon meal, the menu consisted of shrimp, cornbread, cooked sliced squash, rice, and yellow cake with chocolate frosting, and dietary staff member BB was observed overseeing preparation of this meal in the kitchen. During an interview, dietary staff BB confirmed she was not a CDM, stating she had enrolled in but not completed the certification classes. Administrative Nurse D also verified that dietary staff BB did not have dietary manager certification, although she had started the dietary certification classes. The facility’s Nutritional Services Policy, revised 01/21/26, documented that a certified dietary manager would oversee all kitchen procedures, including menu planning, diets and the diet manual with nutritional evaluations, office procedures related to notifying the Registered Dietitian of new elders, food production, and food service, but no such certified individual was in place at the time of the survey.
Failure to Properly Label, Store, and Monitor Food and Equipment Temperatures
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage, distribution, and service practices based on observations, record review, and staff interviews. In the kitchen, a white upright freezer had approximately one-quarter inch of ice buildup along the inside and shelves, and the kitchen refrigerator contained a plastic bag of sliced yellow cheese that was unlabeled and undated. Review of March temperature logs showed missing morning and evening temperature documentation for multiple units, including a chest freezer in dry storage on numerous dates, a white stand-up freezer on several dates, a double-door refrigerator on several dates, and a single-door refrigerator on multiple dates. April logs also lacked documentation of readings for a double-door freezer on specified dates. The facility’s policies required that frozen foods be stored at 0 to -10°F, produce at 38-44°F, dairy at 35-40°F, and that temperature logs be completed and monitored by the Certified Dietary Manager or designee. Additional observations showed sanitation and labeling issues in and around the kitchen and dry storage areas. The ice machine between the kitchen and storage room had a plastic lid and a metal object on the floor behind it, and a plastic green drinking cup sitting on top of the drain underneath it. Eight 15.5-lb plastic jugs of used cooking grease were observed with numerous grayish-black substances on their tops. In dry storage, surveyors found an approximately one-quarter full 5-lb package of undated pasta Labello egg noodles, an approximately one-quarter full 4.5-lb package of unlabeled, undated, unsealed noodles, approximately three-quarters of a full package of undated strawberry gelatin, and an approximately three-quarters full bag of unsealed buttermilk pancake mix. A dietary staff member verified these findings during the survey, and the Dietary Manager later stated that staff were expected to label and date all food placed in dry storage, refrigerators, or freezers when received and when opened, and ensure items were sealed, labeled, and dated with the open date, as outlined in the facility’s written policies.
Failure to Follow Enhanced Barrier Precautions, Hand Hygiene, and Laundry Handling Practices
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective infection prevention and control program, specifically related to Enhanced Barrier Precautions (EBP), hand hygiene, and handling of clean laundry. During tracheostomy care for Resident 2, a licensed nurse performed hand hygiene, donned gloves, and wore a mask but did not don a gown as required under EBP and did not change gloves before placing clean gauze or the tracheostomy cannula. In a separate wound care observation for Resident 6, the same nurse performed hand hygiene and applied a gown and gloves before care, but after completing the wound care and while holding gauze and wound cleanser, the nurse inspected and manipulated the resident’s suprapubic catheter tubing and then left the room without performing hand hygiene. Additional deficiencies were observed in the handling of clean laundry. A housekeeping/laundry staff member placed a covered cart with residents’ personal items in one hall, then removed items from the cart and carried them over the shoulder to another hall without using the cart and without keeping the items covered between rooms. Interviews with nursing and administrative staff confirmed that wound care supplies should be kept in residents’ rooms or bagged and taken to the wound nurse, that hand sanitizing should be performed before and after wound care and after contact with catheters or tubing, and that staff are expected to wear gown, gloves, and mask at minimum for EBP. The housekeeping supervisor also stated that laundry staff are expected to keep the cart covered between rooms. These practices did not align with the facility’s written policies on EBP and hand hygiene, which require targeted gown and glove use during high-contact care and hand cleansing before and after resident contact, after contact with blood or body fluids, after removing PPE, and before procedures involving invasive devices or dressing care.
Inaccurate MDS Coding of Fall With Major Injury
Penalty
Summary
The deficiency involves the facility’s failure to accurately complete the Minimum Data Set (MDS) assessment for Resident 13, resulting in an incorrect coding of the resident’s fall history and injury status. Resident 13’s electronic medical record documented multiple diagnoses, including hemiparesis/hemiplegia, chronic osteomyelitis, and intervertebral disc disorder with radiculopathy. The quarterly MDS dated 03/24/26 recorded a Brief Interview for Mental Status (BIMS) score of 15, indicated the resident required supervision for walking 10 feet and partial assistance for walking 50 feet, and documented that the resident had no falls since the previous MDS assessment. However, this conflicted with clinical documentation and the resident’s care plan and progress notes. On 01/16/26, progress notes showed that staff responded to the resident’s call light and found him on the floor next to his heater, lying on boxes, papers, and his bedside table. The resident complained of back and left hip pain, had swelling behind his left ear from hitting the heater, redness on his left cheek, and reported tenderness with weight-bearing on his leg. A mobile X-ray later confirmed a nondisplaced fracture of the left superior pubic ramus, and the provider assessed the resident the same day. The care plan documented that the resident continued to act independently despite education to use the call light, and the resident later reported to therapy staff that he had falls and was working to get stronger after his last fall. During interviews, an administrative nurse acknowledged that the resident had a fall resulting in a hip fracture that should have been coded on the MDS as a fall with major injury, and that the falls section of the MDS had been coded in error, contrary to the facility’s policy to complete the MDS according to federal regulations and the RAI manual.
Failure to Use Wheelchair Foot Pedals When Assisting a Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide an environment free of accident hazards by not ensuring the use of wheelchair foot pedals when staff assisted a resident in a wheelchair. The resident had diagnoses including severe morbid obesity, vascular dementia, anxiety, and noncompliance, and had a BIMS score of 15 on multiple MDS assessments, indicating intact cognition. The resident’s assessments and Falls Care Area Assessment documented a history of falls within the previous months and identified the resident as being at risk for falls. The care plan documented that the resident was at risk for falls, had experienced a fall, and that his back locked up at times requiring the use of a wheelchair. On one observed occasion, a CNA pushed the resident in a wheelchair without foot pedals attached as he was brought from outside smoking back to his room, during which the resident crossed and held his feet off the floor. On another observed occasion, a nurse turned the resident in his wheelchair and assisted him to the dining room without foot pedals, during which the resident’s sock was half off and dragged on the floor, and the resident again held his foot off the floor. During interviews, one nurse expressed uncertainty about whether the resident should be assisted in the wheelchair without foot pedals, while a CMA stated the resident used foot pedals when being assisted but not when self-propelling. Administrative nursing staff confirmed that staff should not assist the resident in the wheelchair without foot pedals. The facility’s falls policy stated that residents would be assessed for fall risks and interventions implemented to reduce those risks.
Improper Securing of Suprapubic Catheter Tubing
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate care and treatment for a resident with a suprapubic catheter by not securing the catheter tubing according to current standards of practice and the facility’s own competency checklist. The resident had multiple urologic and cognitive conditions, including Alzheimer’s disease with severely impaired cognition (BIMS score of four), chronic kidney disease stage three, benign prostatic hyperplasia, obstructive uropathy, and urinary retention, and was documented as having an indwelling catheter. The care plan included an order from the resident’s urologist directing staff not to remove the catheter and directed staff to apply Skin-prep prior to attaching a Stat-lock for the suprapubic catheter. On two separate observations, licensed nurses assessed and cleaned the suprapubic catheter site on the resident’s abdomen but attached the Stat-lock to the resident’s left upper thigh, securing the tubing from the abdomen to the leg. One nurse confirmed the Stat-lock was attached to the thigh and stated they were unaware that a Stat-lock could be adhered to the abdomen. The administrative nurse stated she expected the Stat-lock to be anchored to the leg and acknowledged that the facility catheter policy did not specify Stat-lock placement for a suprapubic catheter. However, she also stated that the facility’s suprapubic catheter replacement competency checklist, which she had previously reviewed, directed that the catheter tubing should be anchored to the abdomen. The competency checklist documented that the catheter tubing should be secured to the abdomen, but this was not followed in practice.
Failure to Implement Dietitian’s TID Supplement Order and Validate Significant Weight Changes
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate nutritional maintenance for Resident 27 by not implementing the registered dietitian’s recommendation for house supplement shakes three times daily and by not appropriately monitoring and validating significant weight changes. Resident 27 had dementia with severe cognitive impairment, chronic pain, unspecified intellectual disabilities, and major depressive disorder, used a wheelchair, and required set-up or clean-up assistance for eating. The MDS documented a weight of 123 lbs with no weight loss or gain at that time, and the care plan included nutrition-focused interventions such as providing diet as ordered, snacks between meals, monitoring for loss of appetite while on Remeron, and providing supplements as ordered. On 03/03/26, the dietitian documented that the resident had slow, unplanned weight loss related to a decline in energy and recommended offering a house supplement three times a day and adding extra sugar, cream, and butter to foods and fluids to increase energy intake and promote weight stability. Despite this recommendation, the electronic task list from 03/16/26 to 04/13/26 showed the resident was only offered and received a supplement drink once daily in the afternoon. Staff interviews confirmed that the resident received a supplement only on second shift around 2:00 PM, and an administrative nurse acknowledged she had missed the dietitian’s TID recommendation and entered the order for only once daily. Weight records showed a documented weight of 123.4 lbs on 04/01/26 and an implausible weight of 168.0 lbs on 04/10/26, which was not recognized or rechecked at the time by nursing staff. A subsequent re-weigh on 04/15/26, using the wheelchair tare method, yielded a resident weight of 119.5 lbs, reflecting a 3.9 lb (3.16%) loss from 04/01/26. Administrative staff later stated that the 168 lb weight should have been immediately reported and rechecked, and that whoever weighed the resident should have reviewed the previous weight and performed a re-weight if there was a significant change. The facility’s weight loss prevention policy required nutritional interventions and RD consultation for residents with poor or declining intake or weight loss, but the RD was not informed that her TID supplement recommendation had been effectively reduced to once daily.
Emergency Tracheostomy Equipment Not Readily Available at Bedside
Penalty
Summary
The deficiency involves the facility’s failure to ensure that emergency respiratory equipment, specifically an Ambu bag, was readily available at the bedside for a resident with a tracheostomy in the event of accidental extubation or respiratory distress. The resident had diagnoses including sleep apnea, chronic respiratory failure with hypoxia, obesity, dysphagia, malignant neoplasm of the nasopharynx, and required oxygen therapy and tracheostomy care. The resident was cognitively intact, used a wheelchair, and required varying levels of assistance with ADLs. The care plan documented that the resident received breathing treatments, required staff reminders to notify them when treatments were finished, and that staff were to provide oxygen via tracheostomy mask and suction as indicated. The care plan and physician orders also directed staff to call 911 and send the resident to the ER if the entire tracheostomy tube came out, and to follow the facility’s Emergency Protocol Health policy. Surveyor observations on multiple occasions showed that while oxygen and suction were available at the bedside, there was no Ambu bag in the resident’s room. Instead, the Ambu bag and emergency supplies were stored on a covered cart in the hallway under a Hoyer lift, with a battery charger on top, requiring staff to move equipment and wheel the cart into the room before use. Staff interviews confirmed that the emergency tracheostomy supplies and Ambu bag were not kept at the bedside and were instead located in the hallway or medication room. Nursing staff stated that all nurses were CPR-qualified and that hospice residents with tracheostomies had bedside emergency kits because hospice provided them. An administrative nurse reported that tracheostomy care competencies were done annually and explained that there was no emergency kit or Ambu bag at the bedside because the physician had instructed staff not to reinsert the tracheostomy if it came out, but to call 911 immediately. The facility’s Respiratory Care policy stated that necessary respiratory care and services would be provided in accordance with professional standards of practice, the resident’s care plan, and resident choice.
Failure to Implement Timely Interventions to Prevent Facility-Acquired Pressure Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to initiate timely and adequate interventions to prevent the development and progression of a pressure ulcer for Resident 27, who was identified as at risk for pressure ulcer development. The resident had multiple diagnoses including diabetes mellitus, osteoarthritis, heart failure, and muscle weakness, and had a BIMS score of five indicating severely impaired cognition. Assessments documented that the resident required extensive assistance of one to two staff for bed mobility, personal hygiene, dressing, repositioning, and transfers, and that she had a urinary catheter for constant urinary retention and incontinence. The MDS and care plans identified the resident as at risk for skin impairment, with a history of refusing to lie down to relieve pressure from the buttocks, and indicated she was on a turning/repositioning program with nutritional or hydration interventions and a pressure-reducing device in her chair. A Braden Scale score of 16 further indicated risk for pressure ulcer development. Despite these identified risks and care plan directives, the resident developed a facility-acquired Stage 2 pressure ulcer on the left buttocks. Weekly wound assessments documented the presence and progression of an open area on the left buttocks, with measurements changing over time, including a lateral opening measuring 2.0 cm by 1.0 cm and later a left inner buttocks wound measuring 3.0 cm by 2.0 cm by 0.5 cm depth, and then 2.0 cm by 3.5 cm by 0.8 cm depth. The record noted that the resident became less mobile after sustaining a left 5th metatarsal fracture requiring a walking boot, and that she was incontinent and preferred to sit in a recliner and wheelchair rather than sleep in bed. The facility’s own Wound Assessment, Prevention and Treatment policy required timely skin assessments, Braden evaluations, and immediate implementation of plans to reduce pressure ulcer risk, but the development of a facility-acquired pressure ulcer under these known risk conditions demonstrated that timely preventive interventions were not effectively implemented.
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