Family Health & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Wichita, Kansas.
- Location
- 639 S Maize Court, Wichita, Kansas 67209
- CMS Provider Number
- 175501
- Inspections on file
- 18
- Latest survey
- March 4, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Family Health & Rehabilitation Center during CMS and state inspections, most recent first.
Surveyors found multiple sanitation and maintenance deficiencies in several kitchens serving 66 residents, including emergency water cases stored directly on the floor, an oven with heavy burnt residue, and a refrigerator containing an employee lunch bag with resident food. In two kitchens, undated prepared and frozen food items were observed despite dietary staff acknowledging all food should be dated. Additional findings included broken cupboards and missing drawers, heavily scratched cutting boards, bent muffin tins with cooked-on residue, dirty freezer shelves with food and liquid spills, and a dirty shelf under a steamer table. A broken laundry basket containing clean kitchen towels was stored on the floor. These conditions conflicted with facility policy and administrative expectations for clean, well-maintained kitchens and properly labeled food.
A resident with allergic rhinitis, anxiety disorder, and dementia, but intact cognition and no mobility impairment, was observed keeping Fluticasone propionate nasal spray at bedside and self-administering it as needed rather than on a set schedule. The EMR and care plan did not document authorization for self-administration, and the required self-administration assessment tool was not completed, despite facility policy requiring an interdisciplinary competency assessment before allowing medications to be kept in a resident’s room.
A resident with intact cognition but dependent on staff for toileting, dressing, and transfers, and with diagnoses including IBS, HTN, chronic respiratory failure, and urinary retention, had a Falls CAA triggered due to impaired balance, restricted mobility, medication use, need for transfer assistance, and presence of a urinary catheter, with identified risks for falls, injury, pain, and skin breakdown. Despite this, the only documented care plan focus addressed activities, with interventions limited to assisting the resident to and from activities and providing daily education about available activities, and no additional focuses, goals, or interventions were developed for the resident’s clinical and fall-related needs. Nursing staff reported that comprehensive care plans are expected within 21 days of admission, and an administrative nurse acknowledged not realizing that the resident’s comprehensive care plan had not been completed after the resident moved from the skilled unit to the LTC side.
A resident with MS and severe cognitive impairment, who was dependent on staff for oral hygiene, did not consistently receive ordered and care-planned oral care. The care plan and provider orders required staff to assist with toothbrushing twice daily, and dental consults documented poor oral hygiene with heavy food debris and severe gum inflammation, along with instructions to remind and assist with brushing. Surveyors observed morning care without any oral care offered, and the resident’s toothbrush and toothpaste were found dry. The resident’s representative reported ongoing concerns about lack of oral care, an LN admitted signing off oral care without performing it, and a CNA stated she forgot to provide oral care that day, despite acknowledging the resident could not brush independently.
A resident with dementia, chronic constipation, and orders for daily and PRN laxatives went nine days without a documented BM. During this period, ordered Enulose doses were missed on several days because the resident was sleeping, PRN Milk of Magnesia was never given, and there was no documentation of bowel or abdominal assessments. Staff relied on limited electronic bowel documentation and printed reports, and although a standing bowel protocol and assessment requirements were in place for residents approaching three days without a BM, there was no evidence these were initiated or documented for this resident.
A resident with a gastrostomy tube, severely impaired cognition, and total dependence for ADLs had a physician’s order for a daily bolus of Nutrent 2.0 with 100 ml free water flushes before and after each feeding. An LN instead flushed only 50 ml of water before and after administering Zofran via the tube and did not provide the ordered 100 ml flush before the tube feeding, then flushed only 50 ml after the feeding, later acknowledging she misread the order. This failure to follow the ordered water flush regimen occurred despite the care plan directing staff to follow the physician’s orders and an enteral feeding policy addressing order entry and administration.
The facility failed to properly maintain and dispose of outside garbage and refuse. Surveyors observed two outdoor garbage receptacles, including one dumpster with its lid left open, multiple torn garbage bags behind it, and gloves, food, medical supplies, and other trash scattered on the ground. Dietary staff stated that dumpster lids were supposed to remain closed and that no garbage should be on the ground, and administrative staff acknowledged the dumpster was small but still expected staff to keep lids closed and prevent trash accumulation. The facility’s policy required outside dumpsters and surrounding refuse areas to be kept clean, sanitary, and well maintained to prevent nuisance, pest attraction, or contamination risk.
The facility failed to protect a resident and other vulnerable residents during an abuse investigation. The resident reported pain caused by a CNA, but the incident was not immediately reported or investigated according to policy. The CNA continued to work without corrective actions, and administrative staff failed to communicate and report the allegation properly.
The facility failed to ensure accurate reconciliation of controlled substances, with multiple missing signatures on narcotic reconciliation sign-off sheets. Staff confirmed that the sheets should be signed after narcotic counts and key exchanges between shifts, but this was not consistently done. The facility did not provide a policy for controlled medication reconciliation, placing residents at risk of medication misappropriation and diversion.
The facility failed to ensure timely administration of medications and proper insulin pen priming, resulting in a medication error rate of 46.15%. A CMA administered medications outside the allowable timeframe, and an LN did not prime an insulin pen before administration.
The facility failed to ensure safe and secure storage of medications and biologicals, with observations showing unlocked medication refrigerators and carts, and improper maintenance of a refrigerator. Staff interviews confirmed that these storage units should be locked when not in use.
The facility failed to follow consistent infection control standards, including proper signage for EBP, storage of oxygen tubing, indwelling catheter care, laundry handling, and disinfection of shared equipment. Staff did not adhere to hand hygiene protocols, and multiple instances of non-compliance with infection control policies were observed.
The facility failed to ensure that three CNAs had the required 12 hours of in-service education, including dementia management training. The provided training lacked specific directions for staff on interventions and methods of approach for residents with dementia, placing residents at risk for inadequate care.
A resident with multiple medical conditions reported that a CNA hurt her leg during a shower, causing severe pain. The facility failed to report the allegation to the administrator and the State Agency immediately, as required by policy, placing the resident at risk for ongoing abuse or neglect.
The facility failed to implement fall interventions for a resident with quadriplegia, epilepsy, and other conditions, as directed by her care plan. Observations revealed that her bed was not positioned next to the wall, and the fall mat was not in place, putting her at risk of falls. Staff interviews confirmed that the fall precautions were not consistently followed.
The facility failed to follow standards of practice for indwelling catheter care for a resident with severe cognitive impairment and multiple medical diagnoses. Observations revealed the resident's catheter bag was repeatedly found on the floor, and a licensed nurse did not adhere to proper hand hygiene protocols during catheter care. The facility did not provide a policy related to urinary catheter care when requested.
The facility failed to monitor a resident's dialysis access site daily and did not obtain communication from the dialysis center regarding the resident's treatment. The resident had an arteriovenous fistula and required daily assessments, which were not consistently documented, placing the resident at risk of complications.
A resident with multiple diagnoses, including dementia and edema, did not receive a physician-ordered PRN dose of bumetanide despite significant weight gains. This failure to follow the physician's parameters and the facility's medication administration policy was confirmed through record reviews, observations, and staff interviews.
Unsanitary Food Storage and Poor Kitchen Maintenance
Penalty
Summary
Surveyors identified that the facility failed to maintain sanitary food storage and kitchen conditions across four kitchens serving 66 residents. In the main hall food storage room, several cases of emergency water were stored directly on the floor, and dietary staff reported the water had been kept there for a few months. In one house kitchen, the oven contained a large amount of burnt dark residue on the bottom, and the refrigerator held a staff member’s lunch bag stored with resident food items. In two house kitchens, surveyors observed undated containers and bags of food, including cut-up apples with cinnamon, hash browns, and frozen biscuits, and dietary staff acknowledged that all items should have been labeled with dates. Further observations on subsequent days showed multiple areas of disrepair and unclean conditions in the kitchens. Broken cupboards, missing drawers, and very scratched cutting boards were noted, along with muffin bakery tins that were bent and had cooked-on dark black/brown residue. The bottom shelf of a freezer in one kitchen was dirty with drops of food and liquids, and a shelf under a steamer table was dirty with baked-on food and dust. A broken laundry basket labeled for kitchen towels was stored on the floor in a storage area between two houses and contained clean kitchen towels. Administrative staff stated an expectation that kitchen equipment be clean and in good repair, that food be labeled with dates, and that items not be stored on the floor, which contrasted with the conditions observed. The facility’s policy required that food be prepared and served using methods designed to be free of injurious organisms and substances and that the kitchen and equipment be kept clean, neat, orderly, and well maintained.
Failure to Assess Resident for Self-Administration of Nasal Spray Kept at Bedside
Penalty
Summary
The facility failed to ensure a resident was assessed for the ability to safely self-administer a prescribed Fluticasone propionate nasal spray before allowing the medication to be kept at bedside. The resident’s EMR documented diagnoses of allergic rhinitis, anxiety disorder, and unspecified dementia, with annual and quarterly MDS assessments showing a BIMS score of 13, indicating intact cognition, and no impairment in upper or lower extremities. The Psychotropic Drug Use CAA indicated his medications were managed and overseen by the nurse and physician team, and his care plan did not document that he kept the nasal spray at his bedside. The physician’s order specified daily use of Fluticasone propionate nasal suspension for allergic rhinitis, but the Assessment tab lacked the facility’s Self-Administration of Medication/Treatment Data Collection Tool for this medication. During observation, the resident was seen seated in a recliner with a bottle of Fluticasone propionate nasal spray on the dresser directly in front of him, and he stated he administered the nasal spray himself when he felt “stopped up,” rather than on a set schedule. A subsequent observation again found the nasal spray on his dresser. Facility staff, including a licensed nurse and an administrative nurse, confirmed that if a resident had medication in the room, an assessment for self-administration should have been completed, and that no such assessment existed for this resident’s nasal spray. The facility’s self-administration policy stated that resident competency must be assessed by the interdisciplinary team prior to allowing self-administration and that such assessments should be performed annually and after significant changes of condition, but this process was not followed for the resident’s nasal spray.
Failure to Develop Comprehensive Care Plan for High-Risk Resident
Penalty
Summary
Surveyors identified that the facility failed to develop a comprehensive care plan for a resident with multiple medical conditions, including irritable bowel syndrome, hypertension, chronic respiratory failure, and urinary retention. The resident’s admission MDS documented a BIMS score of 14, indicating intact cognition, and showed that she was dependent on staff for toileting, dressing, and transfers, and had experienced one non-injury fall. A Falls Care Area Assessment dated 12/18/25 triggered due to impaired balance with transitions and transfers and the resident’s need for assistance with ADLs. The CAA identified contributing factors such as restricted mobility, medication use, need for assistance with transfers, and the presence of a urinary catheter, and listed risk factors including falls, injuries from falls, pain, and skin breakdown. The CAA stated that a care plan would be reviewed to assist in preventing falls and injuries related to falls. Despite these identified needs and risks, the resident’s care plan contained only one Focus related to activities, initiated on 12/08/25, with interventions limited to assisting the resident to and from activities and educating her daily about available activities. The care plan lacked additional Focus areas, goals, or interventions addressing the resident’s fall risk, impaired balance, dependence in ADLs, catheter care, or other clinical needs. During interviews, nursing staff, including a licensed nurse and administrative nurses, stated that the comprehensive care plan was expected to be completed within 21 days of admission, and one administrative nurse acknowledged she had not realized the resident’s comprehensive care plan had not been developed after the resident moved from the skilled unit to the long-term care side. The facility’s policy on Care Plan Revisions described a care planning process that should include assessment, goal setting, interventions, referrals, evaluation, and revision of care, which was not carried out for this resident.
Failure to Provide Ordered and Care-Planned Oral Hygiene Assistance
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary staff assistance with oral hygiene for a resident with multiple sclerosis and severe cognitive impairment. The resident’s MDS documented dependence on staff for oral hygiene, and the care plan directed that he required supervision and partial/moderate assistance with eating and moderate assistance for oral hygiene, with staff to encourage and/or assist with oral care in the morning and evening. Physician orders required staff to offer to brush the resident’s teeth twice daily, every shift. Dental consultant summaries documented that the resident had missing lower right teeth, heavy food debris, moderate to severe gum inflammation, and poor oral hygiene, while remaining cooperative with cleanings. The dentist left written directions for staff to remind and/or assist the resident with brushing twice daily, focusing on the gumline. Surveyor observations and interviews showed that these ordered and care-planned oral care interventions were not consistently carried out. During morning care, staff assisted the resident but did not offer oral care, and later observation revealed the resident’s toothbrush and toothpaste were present but dry. The resident’s representative reported concerns that staff were not performing oral care as they should and stated she had raised these concerns at a recent care plan meeting. A licensed nurse acknowledged that he did not personally provide oral care but signed it off on the treatment record and then followed up with aides, while a CNA reported she usually did the resident’s oral care after breakfast but had forgotten to do it that day, confirming the resident could not brush his own teeth. The facility’s oral health care policy required oral care twice daily for every resident, but this was not followed for this resident.
Failure to Implement Bowel Protocol for Resident With Prolonged Constipation
Penalty
Summary
The deficiency involves the facility’s failure to identify and implement appropriate interventions for a resident who went nine days without a documented bowel movement despite existing bowel management orders and a bowel protocol. The resident had dementia with severely impaired cognition, required maximal assistance with transfers and toileting, and was frequently incontinent of bowel. The care plan identified chronic constipation and directed staff to administer medications as ordered and monitor for signs of constipation, including no bowel movement for two days when administering narcotics. Physician orders included daily Enulose for constipation and PRN Milk of Magnesia. Record review showed the resident had a small bowel movement on 02/02/26 and then no documented bowel movement from 02/03/26 through 02/11/26, with the next medium bowel movement recorded on 02/12/26. The February MAR indicated Enulose was not administered on three days because the resident was sleeping, and the PRN Milk of Magnesia was not administered at all during the month. Progress notes from 02/02/26 through 02/12/26 lacked evidence that any bowel or abdominal assessments were conducted during the nine-day period without a documented bowel movement. Staff interviews revealed that CNAs and CMAs documented incontinence and bowel movements in separate tasks, and the CMA relied on a dashboard that only displayed 24–48 hours of bowel records, with charge nurses responsible for printing a three-day bowel report. Nursing staff reported there was a standing bowel protocol to be initiated when a resident had no bowel movement for three days, and that nurses were responsible for abdominal assessments and documentation in the EMR. The facility’s bowel and bladder management policy required licensed nurses to review bowel reports each shift, assess residents approaching three days without a bowel movement, and follow a stepwise bowel protocol, but there was no documentation that these assessments or protocol steps were implemented for this resident during the nine-day period without a documented bowel movement.
Failure to Follow Physician’s Orders for Tube Feeding Water Flushes
Penalty
Summary
The deficiency involves the facility’s failure to follow a physician’s order for water flushes before and after medication administration and tube feeding for a resident with a gastrostomy tube. The resident had an artificial opening of the gastrointestinal tract, severely impaired cognition, required total staff assistance with ADLs, and received tube feedings. The resident’s care plan directed staff to provide tube feeding and water flushes per the physician’s order. The physician’s order specified administration of one 250 ml carton of Nutrent 2.0 daily at 10:00 AM, with 100 ml of free water to be flushed through the tube before and after each bolus feeding. During an observation, a licensed nurse donned gloves, placed a catheter tip syringe into the resident’s feeding tube, and administered 50 ml of free water, followed by Zofran dissolved in 15 ml of water, then 250 ml of Nutrent supplement, and finally flushed with 50 ml of water. The nurse confirmed she had flushed the tube with 50 ml of water before and after the Zofran administration and 0 ml before the tube feeding, instead of the ordered 100 ml before and 100 ml after the bolus feeding. The nurse stated she had read the order incorrectly. An administrative nurse later stated her expectation that staff verify the order, position the resident properly, and flush with water per the physician’s order when providing medications and supplements via tube. The facility’s enteral tube feeding policy indicated that bolus supplementation orders would be encoded into the computer under the medication order entry program and handled as unit-dose medications.
Improper Maintenance and Disposal of Outside Garbage and Refuse
Penalty
Summary
The facility failed to properly maintain and dispose of kitchen garbage and refuse in accordance with its policy. With a reported census of 66 residents, surveyors observed two outside garbage receptacles, one on the east side and one on the west side of the building. The dumpster outside of the [NAME] House had a lid open on one side, and several garbage bags with holes in them were found behind the dumpster, with gloves, food, and other medical supplies visible. Additional garbage was observed on the ground on the side of the dumpster. Dietary staff confirmed that dumpster lids were expected to remain closed and that garbage should not be on the ground around the dumpsters. Administrative staff acknowledged that the dumpster in question was small and that she expected staff to keep the lids closed and prevent garbage from accumulating on the ground. The facility’s written Disposal of Garbage and Refuse Policy required that all outside dumpsters and surrounding refuse storage areas be maintained in a clean, sanitary, and well‑maintained condition to prevent nuisance, pest attraction, or potential contamination risk.
Failure to Protect Resident After Abuse Allegation
Penalty
Summary
The facility failed to protect Resident 25 and other vulnerable residents during the investigation of an abuse allegation. Resident 25, who had multiple medical diagnoses including acute kidney failure, deep vein thrombosis, congestive heart failure, depression, and dementia, reported that a Certified Nurse Aide (CNA) was rough with her and caused pain by pulling off her wound cover instead of cutting it off. Despite the resident's report and visible distress, the incident was not immediately reported to the administrator, physician, or family, and no protective measures were taken to separate the alleged perpetrator from the resident or other residents under their care. The facility's investigation into the incident was inadequate. The progress notes and grievance form indicated that the resident reported the incident to staff, but the facility did not follow its own policy for handling abuse allegations. The policy required immediate investigation, assessment of the resident's health and safety, and separation of the alleged perpetrator from the resident. However, the CNA continued to work at the facility without any corrective actions or additional training being implemented. Interviews with administrative staff revealed a lack of communication and proper reporting. Administrative Nurse D did not consider the incident as abuse after reviewing camera footage, and Administrative Staff A was not notified of the allegation until the following morning. The facility's failure to follow its abuse reporting policy and protect Resident 25 and other residents from potential harm constitutes a significant deficiency in care and oversight.
Failure to Ensure Accurate Reconciliation of Controlled Substances
Penalty
Summary
The facility failed to ensure accurate reconciliation of controlled substances, placing residents at risk of medication misappropriation and diversion. Observations revealed that the narcotic reconciliation sign-off sheets on the medication cart in [NAME] House lacked signatures on multiple occasions. Specifically, from 03/07/24 to 03/31/24, there were 11 missing signatures out of 152 opportunities, and from 04/01/24 to 04/21/24, there were 16 missing signatures out of 136 opportunities. Certified Medication Aide (CMA) S and Licensed Nurse (LN) G confirmed that the narcotic sign-on and off sheets should be signed after the narcotic count and key exchange between shifts, but this was not consistently done. Administrative Nurse D also stated that the narcotic sign-on and off sheets were expected to be signed by both the off-going and oncoming nursing staff at the end and beginning of each shift. However, the facility did not provide a policy for controlled medication reconciliation, further contributing to the inconsistency. This failure to ensure accurate reconciliation of controlled substances was consistently completed, placing residents at risk of medication misappropriation and diversion.
Medication Administration Errors
Penalty
Summary
The facility failed to ensure the medication error rate did not exceed five percent when staff did not administer scheduled morning medications to a resident within the ordered timeframe. Specifically, a Certified Medication Aide (CMA) administered medications to a resident at 12:20 PM, well beyond the allowable one-hour window before or after the scheduled administration times of 08:00 AM and 06:00 AM to 10:00 AM. The CMA acknowledged being behind schedule and stated that the medications should have been administered on time. Additionally, a Licensed Nurse (LN) failed to prime an insulin pen and needle before administering insulin to another resident. The LN administered 15 units of insulin without priming the pen and needle with two units of insulin, as required by standard practice. The LN admitted to not being aware of the need to prime the insulin pen and needle before administration. The facility's policy on medication administration, last revised on 01/16/24, requires that medications be administered within a one-hour window before or after the scheduled time. Both the CMA and LN failed to adhere to this policy, resulting in a medication error rate of 46.15%. The facility's administration confirmed the expectations for timely medication administration and proper insulin pen priming, which were not met in these instances.
Failure to Ensure Secure Storage of Medications
Penalty
Summary
The facility failed to ensure safe and secure storage of medications and biologicals, which created a risk for adverse medication effects and ineffective medication administration. Observations revealed that the medication refrigerator on the [NAME] House was left unlocked with unsecured insulin for several residents. Additionally, a medication cart on the same house was found unlocked and unattended by nursing staff. The inside of the refrigerator also had a large amount of ice formation at the top, indicating improper maintenance. Interviews with staff confirmed that medication carts and refrigerators should be locked when not in use or when staff are not in direct sight of them. The facility's policy on Medication Storage, last revised on 02/14/24, did not address the storage of medications in the medication carts or medication refrigerators. This lack of adherence to proper storage protocols was acknowledged by both Licensed Nurse H and Administrative Nurse D, who stated that they expected nursing staff to keep these storage units locked when not in use.
Infection Control Deficiencies
Penalty
Summary
The facility failed to ensure consistent infection control standards were followed in several areas, including enhanced barrier precautions (EBP), storage of oxygen tubing, indwelling catheter care, laundry, and shared equipment. Observations revealed that rooms of residents on EBP lacked the required signage and stored personal protective equipment (PPE) inside the rooms. Additionally, soiled items were found lying directly on the floor in the laundry room, and oxygen tubing was improperly stored in a resident's room without clean storage bags or containers available until the following day. Further deficiencies were noted in the care of a resident with an indwelling catheter, where the urinary catheter bag was repeatedly found lying on the floor, posing a contamination risk. Staff failed to disinfect shared equipment, such as a Hoyer lift, after use, and did not adhere to proper hand hygiene protocols. For instance, a licensed nurse did not change gloves or perform hand hygiene after picking up items from the floor before continuing with catheter care for a resident. Interviews with staff revealed a lack of understanding and adherence to infection control policies. A certified nurse aide and an administrative nurse both acknowledged the importance of proper storage and hygiene practices but admitted that these were not consistently followed. The facility's infection control policy and enhanced barrier precautions guidelines were not effectively implemented, leading to multiple instances of non-compliance and placing residents at risk for complications related to infectious diseases.
Deficiency in CNA Dementia Training
Penalty
Summary
The facility failed to ensure that three Certified Nurse Aides (CNAs) had the required 12 hours of in-service education, including dementia management training. The review of the facility's staffing list revealed that CNAs employed for more than 12 months lacked evidence of dementia in-service training. Specifically, CNA N, hired on 01/19/23, CNA O, hired on 06/16/20, and CNA P, hired on 02/21/22, did not have documented dementia training. The provided in-service training on elopement and communication included slides on dementia but lacked specific directions for staff on interventions and methods of approach for residents with dementia. This deficiency placed residents at risk for inadequate care. Interviews with administrative staff revealed that required in-services were completed electronically, and dementia training was included in the facility's elopement and communication in-services. However, the training lacked comprehensive guidance on providing care to residents with dementia. The facility's policy on required training and in-services documented the need for an effective training program for all staff, including dementia management training. Despite this policy, the facility did not ensure that the reviewed CNA staff received the necessary dementia management training, leading to a deficiency in the quality of care provided to residents.
Failure to Report Allegation of Abuse
Penalty
Summary
The facility failed to ensure staff reported an allegation of staff-to-resident abuse for a resident (R25) to the facility administrator immediately. The resident, who had a history of acute kidney failure, lower extremity deep vein thrombosis, congestive heart failure, depression, and dementia, reported that a Certified Nurse's Aide (CNA) had hurt her leg and was rough with her during a shower. Despite the resident's report of pain and distress, the incident was not reported to the administrator, physician, or family immediately as required by the facility's policy. The facility also failed to report the allegation to the State Agency (SA), placing the resident at risk for unidentified and ongoing abuse or neglect. The resident's Electronic Medical Records (EMR) and Minimum Data Set (MDS) indicated she required assistance with activities of daily living (ADLs) and had a venous ulcer on her lower left extremity. On the night of the incident, the resident reported to nursing staff that the CNA had pulled off her wound cover, causing severe pain and burning sensations. The progress notes and a Resident/Family Concern form documented the resident's complaint, but there was no evidence that the situation was reported to the appropriate authorities immediately. Interviews with administrative staff revealed that the incident was not reported to the SA because the facility reviewed the situation and did not feel it constituted abuse. The facility's policy on Reporting of Abuse, Neglect, and Exploitation (ANE) required all alleged or suspected mistreatment to be reported immediately to the administrator and the SA. The failure to follow this policy resulted in a deficiency, as the resident's allegation of abuse was not handled according to the established procedures, potentially compromising her safety and well-being.
Failure to Implement Fall Interventions for Resident
Penalty
Summary
The facility failed to provide Resident 42's fall interventions as directed by her care plan, placing her at risk of falls and related injuries. Resident 42 had diagnoses of quadriplegia, epilepsy, a feeding tube, and a transient ischemic attack. She was dependent on staff for all activities of daily living and used a wheelchair for mobility. Her care plan included specific fall interventions such as arranging her bed next to the wall and placing a fall mat next to her bed. However, observations on multiple occasions revealed that these interventions were not in place. The bed was not positioned next to the wall, and the fall mat was either rolled up or not in place next to the bed while Resident 42 was in bed. Interviews with staff members, including a Licensed Nurse, a Certified Nursing Aide, and an Administrative Nurse, confirmed that the fall precautions for Resident 42 were not consistently followed. The staff acknowledged that they were responsible for ensuring the safety of each resident and that the care plans, including fall precautions, were discussed during morning huddles and reports. Despite this, the necessary fall interventions for Resident 42 were not implemented, as evidenced by the observations. The facility's Falls policy emphasized the importance of maintaining a safe environment to minimize accident hazards, but this policy was not adhered to in the case of Resident 42.
Failure to Follow Standards of Practice for Indwelling Catheter Care
Penalty
Summary
The facility failed to follow standards of practice related to indwelling catheter care for a resident with severe cognitive impairment and multiple medical diagnoses, including hemiplegia, hemiparesis, and neurogenic bladder dysfunction. The resident required maximal assistance with activities of daily living and had an indwelling urinary catheter. Observations revealed that the resident's catheter bag was repeatedly found on the floor, which is against the care plan instructions to keep the catheter collection bag below the level of the bladder to prevent contamination. Additionally, a licensed nurse was observed performing catheter care without adhering to proper hand hygiene protocols, including failing to change gloves and wash hands after touching soiled surfaces and items, which further increased the risk of infection for the resident. The resident's care plan indicated the need for urinary catheter care each shift and instructed staff to check the tubing for kinks and ensure the catheter collection bag remained below the level of the bladder. However, multiple observations showed that these instructions were not followed. The facility did not provide a policy related to urinary catheter care when requested, indicating a lack of adherence to established standards of practice. This deficiency placed the resident at risk for catheter-related complications, including urinary tract infections.
Failure to Monitor Dialysis Access Site and Obtain Communication from Dialysis Center
Penalty
Summary
The facility failed to monitor a resident's dialysis access site for complications at least daily and did not obtain communication from the dialysis center regarding the resident's treatment. The resident, who had diagnoses of diabetes mellitus, end-stage renal disease, and dependence on dialysis, required staff assistance with toileting needs and had an arteriovenous fistula in her left upper chest. The care plan specified that the nursing staff should monitor the fistula every shift and communicate with the dialysis provider using a written form for each dialysis visit. However, the facility's records showed that staff only assessed the fistula on dialysis days and did not consistently document these assessments or obtain communication from the dialysis center on multiple occasions. Observations and interviews with staff confirmed these deficiencies. A Certified Nurse Aide mentioned assisting the resident with her dialysis bag, while a Licensed Nurse stated that communication forms should be filled out and returned from the dialysis center, and the fistula should be assessed and documented. However, the Licensed Nurse confirmed that the resident's Electronic Medical Record lacked consistent documentation of the fistula assessments. An Administrative Nurse also stated that the fistula should be assessed every shift for bleeding and infection. The facility's Hemodialysis Policy required daily inspection and documentation of the fistula site, but the facility failed to adhere to this policy, placing the resident at risk of potential adverse outcomes and physical complications related to dialysis.
Failure to Administer PRN Medication as Ordered
Penalty
Summary
The facility failed to follow the physician-ordered parameters related to a resident's as-needed (PRN) bumetanide medication. The resident, who had diagnoses including dementia, osteoarthritis, depression, a left femur fracture, and edema, was supposed to receive an additional dose of bumetanide if her weight increased by more than three pounds. Despite multiple instances of weight gain exceeding this threshold, the PRN medication was not administered. This failure was confirmed through record reviews, observations, and staff interviews, indicating a lapse in adhering to the physician's instructions and the facility's medication administration policy. The resident's care plan included instructions to monitor for weight gain or loss due to the use of bumetanide, a medication with a Black Box Warning. The resident's weight history showed significant weight gains on several occasions, yet the additional PRN dose was not given. Interviews with nursing staff and administrative personnel revealed that the staff were expected to follow the physician's parameters, but this was not done in the resident's case. This oversight placed the resident at increased risk for unnecessary medication and side effects.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
