Good Samaritan Society - Liberal
Inspection history, citations, penalties and survey trends for this long-term care facility in Liberal, Kansas.
- Location
- 2160 Zinnia Lane, Liberal, Kansas 67901
- CMS Provider Number
- 175334
- Inspections on file
- 18
- Latest survey
- May 14, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Good Samaritan Society - Liberal during CMS and state inspections, most recent first.
A resident with dementia and behavioral disturbances was able to access multiple lighters and started a fire in her room, leading to the evacuation of all residents. Staff discovered the fire and extinguished it, but inspection revealed the resident had accumulated hazardous items, including lighters and medical equipment belonging to others, due to inadequate supervision and lack of effective monitoring of personal belongings.
The facility failed to ensure the proper functioning of the call light system, leading to significant delays in response times to residents' needs. Additionally, the facility did not appropriately respond to allegations of abuse, including a large bruise on a resident and a reported sexual assault. These failures placed residents at risk for neglect and abuse, impacting their well-being.
A resident reported a sexual assault by two male perpetrators within the facility, but the staff failed to assess her for injuries or report the incident to authorities. Despite the resident's report to hospital staff and subsequent notifications to the facility, no investigation was initiated, and law enforcement was not contacted until much later. This failure placed the resident in immediate jeopardy and at risk for further harm.
A resident reported being sexually assaulted by two male perpetrators, but the facility failed to investigate or notify law enforcement until a surveyor intervened. Despite the resident's cognitive intactness and medical vulnerabilities, the facility did not act on the allegations, leading to a significant oversight in resident safety and well-being.
A resident with a history of trauma and anxiety disorder reported sexual assault multiple times, but the facility failed to investigate or report the allegations to law enforcement. Despite the resident's symptoms of fear and aggression, consistent with a trauma response, the facility did not document the allegations or initiate an investigation until months later, placing the resident in immediate jeopardy.
The facility failed to maintain sanitary conditions in food storage and preparation, risking food-borne illness. Observations revealed undated and improperly stored food items, scratched kitchenware, and burnt substances in ovens. Dietary staff confirmed these issues, which violated the facility's policy requiring proper labeling and storage of opened food.
The facility failed to submit accurate staffing data to CMS, with discrepancies in the Payroll Base Journal (PBJ) showing a lack of 24/7 licensed nurse coverage and low weekend staffing. Despite daily staffing sheets indicating equal staffing levels, the facility lacked a policy to ensure PBJ accuracy, affecting the reported care for 37 residents.
The facility was cited for multiple deficiencies, including four Immediate Jeopardy citations, indicating substandard quality of care. Issues included unreported and uninvestigated abuse allegations, failure to recognize changes in residents' conditions, and lack of comprehensive care plans. The facility also failed to provide necessary care, maintain a safe environment, and serve food under sanitary conditions. Additionally, the administration was ineffective in addressing quality deficiencies, leading to continued substandard care for all residents.
The facility failed to manage its resources effectively, leading to multiple deficiencies in care and administration. Key issues included inadequate response to abuse allegations, failure to perform timely assessments, and inaccurate staffing reports. These deficiencies compromised residents' well-being and quality of care.
A resident with a history of hemiplegia, hemiparesis, and traumatic brain injury experienced a decline in ADLs and increased behavioral issues, which the facility failed to document as a significant change in condition. The resident's functional abilities deteriorated, requiring total dependence on staff for most ADLs, and exhibited increased behaviors such as yelling and hitting. The facility lacked a policy for MDS completion, relying instead on the RAI manual, leading to the oversight.
The facility failed to accurately complete the MDS for several residents, leading to uncommunicated care needs. One resident's MDS did not reflect the use of a chair alarm despite its documented necessity due to frequent falls. Another resident's MDS inaccurately documented the absence of a personal alarm, despite its confirmed use. Additional inaccuracies included incorrect documentation of urinary catheter use, restraint use, and medication classification, highlighting a pattern of incomplete MDS documentation.
The facility failed to provide restorative nursing programs for several residents, including those with severe cognitive impairment, contractures, and functional limitations. Observations revealed that residents did not receive necessary range of motion exercises or splints, despite recommendations from the therapy department. Staff were unaware of any restorative programs, and the facility lacked a system for routine screening to identify residents who would benefit from such programs.
The facility failed to ensure resident safety by not placing a fall mat as required for a resident with severe cognitive impairment and by allowing a single staff member to transfer another resident with a mechanical lift, contrary to policy. These actions led to deficiencies in care and potential safety risks.
A facility failed to follow a Consultant Pharmacist's recommendation to conduct an AIMS assessment for a resident on Risperidone, an antipsychotic medication. Despite the resident's history of traumatic brain injury and behaviors like yelling and hitting, the required assessment was not completed in a timely manner, contrary to facility policy. This oversight was confirmed by the Administrative Nurse, highlighting a lapse in adherence to established procedures.
A resident with a history of falls and intact cognition experienced multiple falls without the care plan being updated for specific incidents. Despite having interventions like a chair alarm and physical therapy consults, the care plan lacked updates for falls on two occasions. Staff interviews confirmed that fall investigations and care plan updates were required but not completed, leading to a deficiency in care planning.
The facility failed to administer medications as ordered for two residents. One resident did not receive Tramadol for seven days due to unavailability, and the facility did not notify the physician or use the emergency kit. Another resident missed a dose of Aspart insulin because it was not available, and the facility did not follow its policy to notify the physician. These failures placed residents at risk for additional medical problems.
A cognitively impaired resident with a history of elopement risk was able to leave the facility unsupervised due to malfunctioning door locks and a failed WanderGuard system. The resident, who was upset and voicing a desire to go home, was found and returned by a neighbor 14 minutes later. Staff were unaware of the elopement until the resident's return.
Failure to Prevent Resident Access to Hazardous Items Resulting in Fire
Penalty
Summary
The facility failed to provide adequate supervision and maintain a safe environment free from accident hazards, resulting in a cognitively impaired resident starting a fire in her room using a cigarette lighter. The resident, who had a history of dementia with behavioral disturbances, confusion, and impaired cognitive function, was able to access and retain multiple lighters in her room. Despite care plans indicating the need for supervision and the use of a WanderGuard due to elopement risk, the resident was left unsupervised in her room, where she ignited her recliner, triggering the facility's smoke alarm. Staff discovered the fire after noticing a glare from the resident's room. Upon entering, they found the resident in her wheelchair next to the burning recliner. The fire was extinguished by CNAs with the assistance of a resident's representative, and all residents were evacuated from the building. Subsequent inspection of the resident's room revealed not only multiple lighters but also various items belonging to other residents, including medical equipment and scissors, indicating a lack of effective monitoring of potentially hazardous items. Interviews and documentation confirmed that the resident had a history of confusion, hallucinations, and delusions, and her cognitive assessments fluctuated from intact to severely impaired. Staff and administrative interviews indicated that the facility was unaware of how the resident obtained the lighters and that there was no effective system in place to prevent unsafe items from entering resident rooms. The failure to supervise the resident and control access to hazardous items directly led to the fire and placed all residents in immediate jeopardy.
Deficiencies in Call Light Response and Abuse Allegation Handling
Penalty
Summary
The facility failed to ensure the proper functioning of the call light system, which resulted in significant delays in response times to residents' needs. Multiple residents reported issues with call light response times, and observations confirmed extended delays, such as a 42-minute response time for one resident. The facility had been aware of the call light system issues for months but did not have adequate measures in place to monitor and address the problem, as evidenced by the absence of staff at the nurses' station to watch the call light system. Additionally, the facility did not appropriately respond to allegations of abuse. One resident had a large bruise across her chest, which was reported to be caused by improper use of a gait belt. However, there was no investigation or documentation of the incident, and the facility failed to educate staff on proper handling to prevent such occurrences. Another resident reported a sexual assault by two men in the facility, but the facility did not investigate the allegation, notify law enforcement, or take steps to protect the resident from further abuse. The facility's failure to address these issues placed residents at risk for neglect and abuse, impacting their physical, mental, and psychosocial well-being. The lack of timely response to call lights and inadequate handling of abuse allegations demonstrated a significant deficiency in the facility's ability to provide a safe and responsive environment for its residents.
Failure to Report and Investigate Sexual Assault Allegation
Penalty
Summary
The facility failed to report and investigate an allegation of sexual assault made by a resident, identified as R17, who was cognitively intact but dependent on care. R17 reported being sexually assaulted by two male perpetrators within the facility on a specific date. Despite the resident's report of bruises and bite marks, the nursing staff did not respond appropriately, failing to assess her for injuries or report the incident to the necessary authorities. The resident later reported the assault to hospital staff during a visit for chest pain, and the hospital notified the facility of the allegation, but the facility still did not take action. The facility's records, including the Electronic Medical Record (EMR) Progress Notes, indicated that R17 had reported the assault to the facility staff, but no investigation was initiated, and law enforcement was not notified until much later when the resident reported the incident to a surveyor. The facility's grievance log did not document any allegations of abuse or neglect regarding R17, and interviews with staff revealed a lack of awareness and education on handling such allegations. The facility's policy required immediate reporting and investigation of abuse allegations, but this was not followed. The failure to act on R17's allegations of sexual assault placed her in immediate jeopardy and at risk for further harm. The facility did not protect the resident or ensure her safety, as required by their policy. The lack of response and investigation into the allegations of abuse was a significant deficiency, as it compromised the resident's physical, mental, and psychosocial well-being.
Failure to Investigate and Report Sexual Assault Allegations
Penalty
Summary
The facility failed to thoroughly investigate and respond to allegations of sexual assault made by a resident, identified as R17. R17, who was cognitively intact but dependent, reported being sexually assaulted by two male perpetrators on multiple occasions. Despite the resident's report of bruises and bite marks, the facility did not conduct a proper investigation or notify law enforcement until the issue was brought to light by a surveyor. The resident's allegations were initially reported to the facility on 05/16/24, and again during a hospital visit on 05/24/24, but the facility did not take appropriate action. R17's medical records indicated a history of traumatic subdural hemorrhage, anxiety disorder, and other conditions requiring assistance with personal care. The resident had a BIMS score indicating intact cognition and had reported feelings of depression and social isolation. Despite these vulnerabilities, the facility did not adequately protect R17 from potential further abuse or investigate the claims. The facility's failure to act on the resident's allegations was compounded by a lack of documentation in the grievance log and a breakdown in communication among staff members. Interviews with facility staff revealed a lack of awareness and education regarding the handling of abuse allegations. The facility's policy required immediate reporting and investigation of such allegations, but this was not followed. The Director of Nursing, Social Services Designee, and other staff members failed to take necessary steps to ensure the resident's safety and well-being, resulting in a significant oversight that placed the resident in immediate jeopardy.
Failure to Respond to Resident's Allegations of Sexual Assault
Penalty
Summary
The facility failed to appropriately respond to a resident's allegations of sexual assault, which were reported on multiple occasions. The resident, who had a history of traumatic subdural hemorrhage and anxiety disorder, reported feeling down, depressed, and isolated. She also experienced hallucinations and delusions. Despite these symptoms and her report of sexual assault, the facility did not take immediate action to investigate or report the allegations to law enforcement. The resident expressed feelings of fear, anger, and aggressiveness, which were consistent with a trauma response. The resident first reported the assault to facility staff on May 16, 2024, stating that two men had sexually assaulted her in the facility. She described having bruises and bite marks, but the facility's nurse did not find any injuries during a skin assessment. The facility's records show that the resident reported the assault again during a hospital visit on May 24, 2024, and upon her return to the facility on May 29, 2024. Despite these reports, the facility did not document the allegations in their grievance log, nor did they initiate an investigation or notify law enforcement until July 16, 2024, when the resident reported the incident to a state agency surveyor. Interviews with facility staff revealed a lack of awareness and action regarding the resident's allegations. The new administrator, who started on June 10, 2024, was not informed of the allegations until July 17, 2024. The facility's policy required immediate reporting and investigation of abuse allegations, but this was not followed. The facility's failure to respond to the resident's allegations of abuse on three different occasions placed the resident in immediate jeopardy and at risk for untreated trauma.
Sanitation Deficiencies in Food Storage and Preparation
Penalty
Summary
The facility failed to store, prepare, and serve food in a sanitary manner, which could potentially lead to food-borne illness among residents. During observations of the kitchen and food storage areas, several issues were identified. A sealed 5-pound bag of cake mix was found without an open date, and a bag of corn bread mix was unsealed. The refrigerator outside the kitchen contained opened containers of orange juice, milk, and chocolate milk, all lacking open dates. Additionally, three frying pans and six cutting boards were found with scratches, and both kitchen ovens had burnt substances on the bottom. The chest freezer contained ice cream with removed lids and freezer-burned cups, as well as an open, undated bag of barbecued pork and a ten-pound bag of frozen vegetables. Dietary Staff BB confirmed these concerns and acknowledged that the undated items were unacceptable. The facility's policy required opened or prepared food to be placed in enclosed containers, dated, labeled, and stored properly, which was not adhered to in this instance.
Inaccurate Staffing Data Submission to CMS
Penalty
Summary
The facility failed to electronically submit complete and accurate direct care staffing information to the Centers for Medicare and Medicaid Services (CMS) as required. Specifically, the facility's Payroll Base Journal (PBJ) Staffing Data Report for fiscal year Quarter 3, 2023, showed a lack of licensed nurse coverage for 24 hours a day, seven days a week on several specific dates. Additionally, the PBJ reports for subsequent quarters indicated excessively low weekend staffing, despite daily staffing sheets showing equal staffing levels on weekends and weekdays. This discrepancy was confirmed by Administrative Nurse D, who reported that the Administrator compiles and transmits the staff hours to CMS. The facility did not have a policy in place to ensure the accuracy of the PBJ submissions. The report highlights that the facility's failure to provide accurate staffing data included information for agency and contract staff, which should be based on payroll and other verifiable and auditable data in a uniform format as specified by CMS. The facility reported a census of 37 residents at the time of the survey, but the inaccurate staffing data submission could potentially impact the quality of care provided to these residents.
Multiple Deficiencies and Immediate Jeopardy in Facility Care
Penalty
Summary
The facility was found to have multiple deficiencies during the recertification survey, including four Immediate Jeopardy (IJ) citations, which indicated substandard quality of care. These deficiencies were not identified by the facility's Quality Assurance and Performance Improvement (QAPI) program, affecting all 37 residents. The surveyors discovered issues such as abuse, lack of reporting and investigating abuse allegations, and failure to protect residents from further abuse. Additionally, the facility did not recognize significant changes in residents' conditions, failed to complete required assessments, and did not develop comprehensive care plans. The survey revealed that the facility failed to provide necessary care and services to maintain residents' well-being. Specific incidents included the failure to revise fall care plans, provide scheduled pain medication, and respond to pharmacist recommendations. The facility also did not ensure a safe environment, as evidenced by improper use of mechanical lifts and failure to document fall prevention measures. Furthermore, the facility did not serve food under sanitary conditions, potentially leading to foodborne illnesses. The facility's administration was ineffective in identifying and addressing quality deficiencies, as evidenced by inaccurate reporting of staffing information and failure to maintain corrective measures from previous surveys. The lack of an effective QAPI program resulted in continued substandard care, placing all residents at risk for decreased quality of life and well-being.
Ineffective Administration and Resource Management
Penalty
Summary
The facility failed to administer its resources effectively and efficiently, compromising the quality of care and well-being of its residents. Key deficiencies included the lack of an effective Quality Assessment and Performance Improvement (QAPI) program, as evidenced by multiple deficient practices and substandard quality of care. The facility did not ensure staff appropriately identified and responded to allegations of abuse, including a resident's report of sexual assault, and failed to report these allegations to the State Agency or local law enforcement as required. Additionally, the facility did not investigate all allegations of resident-to-resident abuse or protect residents from further incidents. There was also a failure to recognize significant changes in residents' conditions and perform timely assessments, which could lead to uncommunicated needs and further deterioration of residents' well-being. The facility's administration was ineffective in developing comprehensive, person-centered care plans and revising fall care plans with necessary interventions. It failed to provide necessary care and services to maintain residents' highest practicable well-being, including issues related to the Restorative Nursing Program and safe transfer procedures. The facility did not provide scheduled pain medication as ordered, respond to pharmacist recommendations, or serve food under sanitary conditions. Furthermore, the facility failed to accurately report staffing information to CMS, which included incorrect reporting of RN coverage. These deficiencies placed residents at risk for decreased quality of care, treatment, and overall well-being.
Failure to Capture Significant Change in Resident's Condition
Penalty
Summary
The facility failed to identify and document a significant change in condition for a resident, who experienced a decline in activities of daily living (ADLs) and an increase in behavioral issues. The resident, who had a history of hemiplegia, hemiparesis, traumatic brain injury, and severely impaired cognition, showed a marked decline in functional abilities between assessments. Initially, the resident required supervision for eating and oral care, moderate assistance with ADLs, and maximal assistance with transfers and personal hygiene. However, by the next assessment, the resident required total dependence on staff for most ADLs and exhibited increased behaviors such as yelling and hitting. Despite these changes, the facility did not capture this significant change in the resident's condition, as evidenced by the lack of a policy for Minimum Data Set (MDS) completion and reliance on the Resident Assessment Instrument (RAI) manual. The resident's behaviors were documented in progress notes, indicating frequent mood behaviors and difficulty in redirection by staff. The failure to recognize and document these changes had the potential to negatively impact the resident's physical, mental, and psychosocial well-being.
Inaccurate MDS Documentation Leads to Uncommunicated Care Needs
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) for several residents, leading to uncommunicated care needs. For one resident, the MDS did not reflect the use of a chair alarm, despite documentation in the care plan and physician orders indicating its necessity due to frequent falls. The resident had a history of falls and was found on the floor on multiple occasions, yet the MDS section for alarms was not completed correctly. Interviews with staff confirmed the presence of the alarm, but the facility lacked a specific policy for MDS completion, relying instead on the Resident Assessment Instrument (RAI) manual. Another resident's MDS inaccurately documented the absence of a personal alarm, despite observations and staff interviews confirming its use for several months. The resident had severe cognitive impairment and required significant assistance with activities of daily living. The care plan, physician orders, and progress notes did not mention the alarm, and the MDS was not updated to reflect its use. This oversight was acknowledged by administrative staff, who again cited reliance on the RAI manual for MDS completion. Additional inaccuracies were found in the MDS for other residents, including incorrect documentation of urinary catheter use and restraint use. One resident's MDS inaccurately indicated the use of multiple types of catheters, while another resident's MDS incorrectly noted the use of physical restraints, which the resident denied. Furthermore, a resident receiving antipsychotic medication was not accurately documented in the MDS, with the medication being misclassified. These errors highlight a pattern of incomplete and inaccurate MDS documentation, which could lead to unmet care needs for the residents.
Failure to Provide Restorative Nursing Programs
Penalty
Summary
The facility failed to provide appropriate restorative nursing programs for several residents, leading to deficiencies in maintaining or improving their range of motion and mobility. Resident 4, who had severe cognitive impairment and functional limitations due to hemiplegia and osteoporosis, did not receive therapy or restorative nursing programs. Observations revealed that the resident was not provided with passive range of motion exercises or the necessary splints to prevent contractures, despite recommendations from the therapy department. The restorative aide confirmed that no routine restorative nursing programs were being provided due to time constraints and lack of assessments. Similarly, Resident 11, who had severe cognitive impairment and a stage four pressure ulcer, did not receive the necessary restorative nursing care to prevent worsening contractures. The resident's care plan included interventions for contractures, but observations showed that no range of motion exercises or splints were applied during care. Staff members were unaware of any restorative nursing programs, and the facility lacked a system for routine screening to identify residents who would benefit from such programs. Resident 29, with a history of cerebral infarction and traumatic brain injury, also did not receive restorative nursing programs despite having functional limitations in range of motion. Observations indicated that the resident did not receive exercises or assistance with range of motion during meals. The facility's policy on restorative nursing care was not implemented, and the therapy department's recommendations for continued restorative services were not followed. Additionally, Resident 8, who had dementia and contractures in both lower extremities, did not receive a restorative nursing program to prevent further decline, as recommended by the therapy department. The facility's failure to provide these services placed residents at risk for further decline and discomfort.
Deficiencies in Resident Safety and Transfer Protocols
Penalty
Summary
The facility failed to maintain an environment free from accident hazards for two residents, leading to deficiencies in care. For one resident, who had severe cognitive impairment and required maximal assistance with activities of daily living, the facility did not consistently place a fall mat next to the resident's bed as per the care plan. On one occasion, the resident was found on the floor next to the bed, with the fall mat improperly placed by the window. A Certified Nurse Aide admitted to forgetting to place the mat, which was a required safety intervention documented in the care plan. Another deficiency involved the unsafe transfer of a resident with severe cognitive impairment and a cerebral aneurysm. The resident's care plan required a total lift transfer with two-person assistance. However, a Certified Nurse Aide transferred the resident alone using a full body mechanical lift, contrary to the facility's policy that mandates two staff members for such transfers. The aide acknowledged the breach, citing the unavailability of other aides at the time. These incidents highlight the facility's failure to adhere to established care plans and policies, potentially compromising resident safety. The lack of proper execution of safety interventions and adherence to transfer protocols were directly observed and reported by staff, indicating lapses in following prescribed procedures for resident care.
Failure to Conduct Timely AIMS Assessment for Resident on Antipsychotic
Penalty
Summary
The facility failed to adhere to the Consultant Pharmacist's recommendations regarding the completion of an Abnormal Involuntary Movement Scale (AIMS) assessment for a resident receiving Risperidone, an antipsychotic medication. The resident, who had a history of traumatic brain injury and exhibited behaviors such as yelling and hitting, was prescribed Risperidone to manage these behaviors. Despite the Consultant Pharmacist's recommendations on multiple occasions to conduct an AIMS assessment to monitor for tardive dyskinesia, a potential side effect of Risperidone, the facility did not complete the assessment in a timely manner. The resident's medical records indicated severely impaired cognition and a history of behaviors that warranted the use of antipsychotic medication. The facility's policy required an AIMS assessment to be conducted every six months, but the assessments were overlooked, as confirmed by the Administrative Nurse. This oversight was contrary to the facility's policy and the Consultant Pharmacist's recommendations, potentially impacting the resident's well-being.
Failure to Update Care Plan After Resident Falls
Penalty
Summary
The facility failed to accurately update the care plan for a resident, identified as R7, following multiple falls. R7's electronic health record indicated a history of falls, along with diagnoses of metabolic encephalopathy, muscle weakness, anxiety disorder, and intact cognition. Despite these conditions, the care plan lacked interventions for falls that occurred on January 26, 2024, and April 15, 2024. The care plan did include some interventions, such as the use of a chair alarm and physical therapy consults, but these were not updated following the aforementioned falls. The facility's policy required documentation for any necessary updates to the care plan, which was not adhered to in this case. The report detailed several incidents where R7 was found on the floor, including falls in the bathroom, room, and whirlpool room, with varying degrees of injury. Interviews with staff revealed that a fall investigation should be conducted after each incident, and the care plan should be updated accordingly. However, it was confirmed that the care plan lacked interventions for specific falls, placing the resident at risk for uncommunicated care needs. The facility's failure to update the care plan as required by their policy and state regulations led to this deficiency.
Medication Administration Failures
Penalty
Summary
The facility failed to ensure that two residents received their medications as ordered by their physicians. Resident 8, who has diagnoses including dementia and osteoarthritis, did not receive their prescribed Tramadol for seven days. The medication was not available, and the facility staff failed to notify the physician or obtain the medication from the emergency kit. The resident's electronic health record and medication administration record indicated that the medication was unavailable on multiple occasions, and the facility was unable to locate the narcotic sign-off record for the missing dates. Resident 16, diagnosed with diabetes mellitus and altered mental status, did not receive their prescribed Aspart insulin on one occasion. The facility staff documented that the medication was not available, and the insulin was not administered as per the sliding scale orders. The facility's policy required that if a medication is not available for 24 hours, the physician must be notified, but this was not done in a timely manner. The facility's failure to administer medications as ordered placed both residents at risk for additional medical problems. The facility's policies on medication administration and ordering from the pharmacy were not followed, leading to these deficiencies. The lack of communication and failure to utilize the emergency kit contributed to the residents not receiving their necessary medications.
Failure to Prevent Elopement of Cognitively Impaired Resident
Penalty
Summary
The facility failed to provide adequate supervision and a safe environment for a cognitively impaired resident identified as an elopement risk. The resident, who had diagnoses of Alzheimer's disease, altered mental status, restlessness, agitation, and dementia, was left unsupervised near the front entrance despite being upset and voicing a desire to go home. The front doors, which were known to be malfunctioning and did not require a code to open, allowed the resident to exit the facility without staff awareness. Additionally, the WanderGuard system, which was supposed to alert staff when the resident approached the exit, failed to alarm. The resident was found and returned to the facility by a neighbor 14 minutes later, uninjured but without staff knowledge of her elopement until her return. The resident's medical records and care plan indicated that she had severe cognitive impairment, used a wheelchair for mobility, and was at risk for elopement. The care plan included the use of a WanderGuard bracelet to alert staff to her movements near exit doors and required staff to check the WanderGuard daily. Despite these measures, the resident was able to leave the facility due to the malfunctioning door lock and the failure of the WanderGuard system. Staff interviews revealed that the resident had been upset and crying throughout the day, asking to go home, and was last seen by staff shortly before her elopement. Maintenance staff confirmed that the WanderGuard system and door locks had been checked and were reported to be functioning properly prior to the incident. Observations and interviews with staff indicated that the resident had been left unsupervised near the front entrance, and staff were unaware of her elopement until she was brought back by a neighbor. The facility's policy on elopement required measures to minimize the risk of elopement, but these measures were not effectively implemented in this case. The failure to provide adequate supervision and a safe environment for the resident, who was known to be an elopement risk, resulted in her leaving the facility without staff knowledge and placed her in immediate jeopardy.
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.
The facility failed to coordinate hospice services within the care plans for two residents receiving hospice. Both residents had severe cognitive impairment and extensive ADL needs, and their MDS assessments documented hospice care. Their care plans included general directions about ADL assistance, pain monitoring, and consulting with hospice or the physician, but omitted key hospice-specific details such as hospice contact information, visit schedules, services to be provided, and what supplies, equipment, and medications hospice would furnish. Clinical record review and interviews with an administrative nurse confirmed that there was no documented coordination between hospice and facility care plans, contrary to the facility’s hospice policy requiring an interdisciplinary plan integrating hospice and facility services.
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 Coordinate Hospice Services in Resident Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to develop and maintain a coordinated hospice plan of care that integrated hospice services with facility services for two residents receiving hospice. For one resident with Alzheimer’s disease, CAD, and atrial fibrillation, the Significant Change MDS documented severely impaired cognition and extensive assistance needs for bed mobility and transfers, and indicated the resident was receiving hospice services. The resident’s care plan noted a terminal prognosis due to Alzheimer’s, directed staff to adjust ADL care, consult the physician for hospice care in the facility, and monitor and treat pain, but it did not include instructions on hospice services such as hospice staff visit schedules, supplies, medical equipment, or medications covered by hospice. The clinical record showed the resident had been admitted to hospice care months earlier, yet there was no documented evidence of coordination of care between hospice and the facility. For the second resident, diagnosed with PVD, DM, HTN, and atherosclerotic heart disease, the Significant Change MDS showed severe cognitive impairment with a BIMS score of two and dependence on staff for most ADLs, and documented that the resident received hospice services. The resident’s care plan recorded admission to hospice and directed staff to adjust ADL provision, encourage participation as desired, assess coping, respect wishes, and consult with the physician and hospice for continuing hospice care, as well as monitor for pain and notify the physician and hospice for breakthrough pain. However, the care plan lacked a hospice contact number, information on what supplies, equipment, and medications hospice would provide, and details on when hospice staff would be in the building and what care they would deliver. Observations and staff interviews confirmed these omissions. One resident was observed in bed receiving eye drops from a CMA, and during record review, the Administrative Nurse acknowledged that the facility care plan lacked specific information coordinating with the hospice care plan. For the second resident, the Administrative Nurse verified that the care plan did not contain information regarding hospice visits, phone numbers, or medical supplies provided by hospice, and stated that such information should be on the resident’s care plan. These findings were inconsistent with the facility’s Hospice Services policy, which required an interdisciplinary care plan integrating facility and hospice services, including coordination of services and supplies provided by the hospice provider.
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