Ignite Medical Resort Rainbow Boulevard, Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Kansas City, Kansas.
- Location
- 3910 Rainbow Blvd, Suite 400, Kansas City, Kansas 66103
- CMS Provider Number
- 175544
- Inspections on file
- 26
- Latest survey
- March 19, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Ignite Medical Resort Rainbow Boulevard, Llc during CMS and state inspections, most recent first.
A resident with severe cognitive and physical impairments was admitted with existing skin issues, but staff failed to conduct a thorough skin assessment or document a stage 3 sacral pressure ulcer until four days after admission. The care plan lacked specific interventions for the wound, and required risk assessments were not completed, resulting in delayed identification and management of the pressure ulcer.
A resident with severe cognitive impairment and physical limitations fell and sustained a head injury when a CNA attempted to provide incontinence care alone, despite the care plan requiring two-person assistance. The resident, who was at high risk for falls, rolled off the bed during the incident, highlighting a failure to ensure a safe environment.
The facility failed to ensure RN coverage for eight consecutive hours daily, seven days a week, as required. A review of nursing hour sheets and a labor report revealed multiple dates without adequate RN coverage, placing 93 residents at risk of inadequate assessment and care. Administrative staff were involved in verifying schedules, but no policy on RN coverage was provided.
The facility failed to follow infection control standards, particularly in the use of PPE for Enhanced Barrier Precautions, as observed when a nurse changed a resident's wound dressing without wearing a gown. Additionally, the facility lacked a water management program to address Legionella risk, with administrative staff acknowledging the absence of such a program. These deficiencies increased the risk of infectious diseases among residents.
The facility failed to secure hazardous materials and rooms from nine cognitively impaired ambulatory mobile residents, placing them at risk for preventable accidents. Unsecured electrical rooms and cleaning closets with hazardous materials were found, contrary to the facility's policy. Staff confirmed these areas should have been locked to prevent resident access.
The facility failed to securely store medications by not locking three medication carts, which contained insulin pens and medicated creams. Inspections revealed that the carts were left unattended and unlocked, contrary to the facility's policy. LN H admitted that night shift staff sometimes forget to lock the carts, and Administrative Nurse D confirmed that carts should be locked when not in use.
A facility with 93 residents was found to have deficiencies in food storage and labeling practices. Observations revealed unlabeled and undated food items in the main kitchen, including shredded cheese, cake, and deli meats. The 400-floor kitchenette area also had unsanitary conditions, such as sugar granules on counters and water deposit stains. Dietary staff confirmed the need for proper labeling and storage to prevent contamination, but the facility failed to adhere to these standards, risking food-borne illnesses.
The facility failed to ensure agency staff received required training on resident rights, impacting care quality. The facility relied on a sister agency for training records, which were not provided, and lacked a policy for direct care staff education.
The facility did not ensure agency staff received required training on abuse, neglect, and exploitation (ANE), placing residents at risk. The facility could not provide training records for an agency LN and relied on a sister company to maintain these records. The facility also lacked a policy for required education for direct care staff.
The facility failed to ensure agency staff received required infection control training, placing residents at increased risk for infections. The facility could not provide training records for an agency LN and relied on a sister company to maintain these records. Additionally, the facility lacked a policy for required education for direct care staff.
A resident with multiple medical conditions, including blindness, was observed in the dining area with an open gown, exposing his backside. Despite being independent in some activities, he relied on staff for dressing assistance. Staff interviews confirmed the expectation for residents to be appropriately covered, aligning with the facility's dignity policy. The failure to ensure proper dressing compromised the resident's dignity.
A facility failed to provide timely written notification of transfer to a resident or their representative for several facility-initiated transfers. The resident, with a history of neuromuscular dysfunction, CHF, and paraplegia, had multiple unplanned discharges to a hospital without documented notifications. Staff interviews revealed a lack of adherence to the facility's bed hold policy, which required written notification before transfer or within 24 hours in emergencies.
A resident with end-stage renal disease and a newly placed AV fistula did not have her care plan updated to include necessary interventions for dialysis access site monitoring. The facility's oversight in revising the care plan placed the resident at risk for impaired care due to uncommunicated care needs.
A facility failed to properly manage a resident's suprapubic catheter, leading to a deficiency. The resident, with a history of chronic kidney disease and bladder dysfunction, had a catheter anchored on the thigh instead of the abdomen, causing potential complications. Staff interviews revealed uncertainty about proper catheter anchoring, and the care plan lacked specific instructions, placing the resident at risk.
A facility failed to ensure proper communication and monitoring for a resident requiring dialysis. The resident's care plan lacked specific directions for monitoring a dialysis fistula, and the facility did not maintain documentation of monitoring the AV fistula shunt access site. Additionally, communication with the dialysis center was inadequate, as dialysis communication forms were missing for several months. This placed the resident at risk for complications related to dialysis.
A facility failed to assess the risks of bed rail use for a resident with a low air-loss mattress, despite the presence of a right-sided assist bar. The resident's evaluations did not address the potential risks associated with the mattress, and the care plan lacked documentation on bed rails. Staff interviews revealed inconsistent monitoring and assessment practices, contrary to the facility's policy, placing the resident at risk for impaired safety.
A facility failed to ensure a resident's PRN hydroxyzine had a 14-day stop date or physician documentation for extended use. The resident, with a history of hypertension, CHF, diabetes, and obesity, was taking an antianxiety medication. The facility's policy required a stop date or physician guidance for PRN psychotropic medications, which was not followed.
The facility failed to secure hazardous materials when a Sharps container on a medication cart was found overfilled past the fill line, with lancets accessible. An unidentified staff member used bare hands to push the contents back into the bin. This placed four cognitively impaired, independently mobile residents at risk for preventable injuries and accidents.
The facility failed to follow sanitary dietary standards for food storage and maintaining a sanitary food service environment. Inspections revealed old food particles, stains, expired and undated food items, and calcium-encrusted stains in kitchenettes on the third and fourth floors. Dietary staff acknowledged that the kitchenettes should be managed by contracted dining services, but these practices were not followed.
The facility failed to meet a resident's behavioral health needs, resulting in repeated episodes of verbal and physical aggression towards other residents and staff. Despite having a care plan, non-pharmacological interventions were inconsistently applied and documented, leading to multiple incidents of aggression.
Failure to Timely Identify and Manage Pressure Ulcer on Admission
Penalty
Summary
A resident with significant cognitive and physical impairments, including hemiplegia, Parkinson's disease, seizures, muscle weakness, and dementia, was admitted to the facility. Upon admission, the resident was dependent on staff for all activities of daily living and was incontinent of bowel and bladder. The initial admission assessment documented excoriation to the groin and abdominal fold, a left chest surgical incision, and shearing to the inner buttock, but did not provide detailed descriptions or identify a stage 3 sacral wound. The care plan noted the resident was at risk for skin integrity issues but lacked specific interventions or documentation for the existing stage 3 sacral wound. For four days following admission, there was no documentation in the daily skilled nurses' notes regarding assessment or care for a stage 3 sacral pressure ulcer. The sacral wound was only identified and documented on the fourth day after admission, at which point a wound care consult and specific wound care orders were implemented. Prior to this, the care plan and assessments did not reflect the presence or management of the sacral wound, and no Braden risk scores were recorded to assess the resident's risk for pressure ulcers. Interviews with facility staff revealed that the initial skin assessment should have been completed within 24 hours of admission, but this was not done in detail for this resident. The facility's wound policy required a comprehensive head-to-toe skin assessment and risk scoring upon admission, which was not followed. The lack of timely identification and documentation of the resident's stage 3 sacral pressure ulcer resulted in a delay in appropriate care and placed the resident at risk for harm.
Failure to Provide Adequate Assistance Leads to Resident Fall
Penalty
Summary
The facility failed to ensure a safe environment for a resident, identified as R1, who was at high risk for falls due to severe cognitive impairment and physical limitations following a stroke. R1 required two-person assistance for all activities of daily living, including incontinence care, as documented in their care plan. Despite this requirement, a Certified Nurse Aide (CNA) attempted to provide incontinence care alone, during which R1 rolled off the bed and sustained a head injury. The incident was witnessed, and the resident was subsequently taken to the emergency room, where imaging showed no significant injury. R1's medical history included cerebral infarction, hemiplegia, hemiparesis, and stage 3 chronic kidney disease, which contributed to their high fall risk. The care plan had previously documented two non-injury falls and directed staff to use bilateral fall mats and maintain the bed in a low position. However, during the incident, these precautions were not sufficient to prevent the fall. The facility did not provide a policy for the prevention of accident hazards, and the failure to adhere to the care plan's requirement for two-person assistance directly led to the resident's fall and injury.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to provide Registered Nurse (RN) coverage for eight consecutive hours a day, seven days a week, as required. This deficiency was identified through a review of daily posted nursing hour sheets from March 1, 2023, to August 15, 2024, which revealed multiple dates lacking RN coverage. Specifically, the facility's Rainbow Labor report, submitted on August 26, 2024, showed no evidence of eight consecutive hours of RN coverage on March 14, 2024, March 18, 2024, May 18, 2024, June 6, 2024, and June 15, 2024. Administrative Staff A and Administrative Nurse D were involved in checking schedules and reviewing timecards to verify RN coverage, but the facility did not provide a policy related to RN coverage. This lack of RN coverage placed all 93 residents of the facility at risk of inadequate assessment and inappropriate care, as there was no assurance that a registered nurse was available to meet their needs consistently.
Infection Control and Water Management Deficiencies
Penalty
Summary
The facility, with a census of 93 residents, failed to adhere to infection control standards, particularly in the use of personal protective equipment (PPE) for Enhanced Barrier Precautions (EBP). This was observed when a licensed nurse entered a resident's room, which had signage indicating the need for EBP, and proceeded to change the resident's wound dressing without wearing a gown as required. Despite the facility's policy and training on EBP, this lapse in following the protocol was noted, indicating a failure in implementing the infection prevention and control program effectively. Additionally, the facility did not have a water management program to address and mitigate the risk of Legionella and other waterborne pathogens. When requested, the facility was unable to provide a risk assessment or a water management program for Legionella. Administrative staff acknowledged the absence of such a program, attributing it to the building's ownership. This lack of a water management program further contributed to the facility's failure to maintain sanitary infection control standards, placing residents at increased risk for infectious diseases.
Failure to Secure Hazardous Areas and Materials
Penalty
Summary
The facility failed to secure hazardous materials and rooms from nine cognitively impaired ambulatory mobile residents, placing them at risk for preventable accidents and injuries. During a walk-through of the facility's fourth floor, it was observed that two electrical rooms were unsecured. One room, located across from a resident's room, contained two large unlocked high-voltage switch panels with warnings indicating the danger of hazardous voltage. Another room across from a different resident's room had six smaller unlocked electrical switch panels with similar warnings. Additionally, a cleaning closet across from a resident's room was found unsecured, containing various hazardous cleaning products with warnings about potential harm. Further observations on the third floor revealed that the facility's beauty salon was left unlocked, with an unlocked cabinet containing several bottles of sanitizing spray and barbicide, both labeled as hazardous. Interviews with staff, including a Licensed Nurse and an Administrative Nurse, confirmed that these areas should have been locked at all times to prevent resident access to potentially hazardous materials. The facility's policy on the control of hazardous chemicals, revised in June 2024, indicated that such materials should be securely stored and inaccessible to residents, which was not adhered to in this instance.
Medication Storage Deficiency
Penalty
Summary
The facility failed to securely store medications, specifically insulin pens and medicated creams and ointments, by not locking three medication carts. During an inspection, it was observed that a treatment cart stationed across from the fourth-floor elevators was left unsupervised and unlocked, containing 12 labeled but unsecured insulin pens. Another cart, located next to the fourth-floor rehab gym entry, was also found unattended and unlocked, containing 10 labeled insulin pens and assorted medicated creams and ointments. A third cart, across the hall from a resident's room, was similarly unsecured with six insulin pens and various medicated creams and ointments. Licensed Nurse H acknowledged that sometimes the night shift staff forgets to lock the carts after moving items between them. Administrative Nurse D confirmed that medication carts should be locked when not in use or directly monitored. The facility's Medication Access and Storage policy, reviewed in January 2023, mandates that all medications and biologicals be stored safely and securely, following the manufacturer's storage recommendations. The failure to adhere to this policy placed residents at risk for unsafe medication practices and potential misappropriation.
Deficiencies in Food Storage and Labeling Practices
Penalty
Summary
The facility, with a census of 93 residents, was found to have deficiencies in food storage and labeling practices during a survey. Observations in the main kitchen revealed several food items, including containers of shredded cheese, slices of cake, and various deli meats, that were not labeled or dated after their original packaging was opened. Additionally, a half onion was found in a plastic bag without a label or date. These practices were contrary to the facility's policy, which requires all opened food items to be placed in sealed containers and labeled with the name of the food, the date it was opened, and the expiration date. Further inspection of the 400-floor kitchenette area showed unsanitary conditions, such as sugar granules on the counters and water deposit stains around the water and ice machine dispenser spout. Interviews with dietary staff confirmed that all food items should be labeled and stored properly to prevent contamination and the growth of pathogenic organisms. The facility's failure to adhere to these standards placed residents at risk of food-borne illnesses and food safety concerns.
Failure to Provide Resident Rights Training to Agency Staff
Penalty
Summary
The facility, with a census of 93 residents, failed to ensure that agency staff received the required training on resident rights, which is essential for providing proper care and maintaining the quality of life for residents. On a specific date, the facility was unable to provide training records for an agency Licensed Nurse (LN) identified as K. During an interview, Administrative Staff A revealed that the facility relied on the agency company, which is a sister company, to ensure that the required education was provided and records were maintained. However, the facility was still waiting for the agency to send the requested staff information. Additionally, the facility did not have a policy related to the required education for direct care staff, leading to a deficiency in ensuring agency staff received necessary training.
Failure to Provide ANE Training to Agency Staff
Penalty
Summary
The facility failed to ensure that agency staff received the required training on abuse, neglect, and exploitation (ANE), which placed residents at risk. The facility had a census of 93 residents and was unable to provide training records for an agency Licensed Nurse (LN) identified as K. During an interview, Administrative Staff A stated that the facility relied on the agency company, which was a sister company, to ensure that the required education was provided and records were maintained. However, the facility was still waiting for the agency to send the requested staff information. Additionally, the facility did not have a policy related to the required education for direct care staff.
Infection Control Training Deficiency
Penalty
Summary
The facility failed to ensure that agency staff received the required infection control training, which placed residents at increased risk for infections. The facility had a census of 93 residents and was unable to provide training records for an agency Licensed Nurse (LN) identified as K. During an interview, Administrative Staff A stated that the facility relied on the agency company, which was a sister company, to ensure that the required education was provided and records were maintained. However, the facility was still waiting for the agency to send the requested staff information. Additionally, the facility was unable to provide a policy related to the required education for direct care staff, further contributing to the deficiency.
Resident Dignity Compromised Due to Inadequate Dressing
Penalty
Summary
The facility failed to maintain a dignified care environment for a resident, identified as R51, during mealtime. R51, who has a medical history including respiratory failure, hypertension, diabetes, and blindness, was observed in the dining area with his gown open at the back, exposing his backside to peers and visitors. Despite having intact cognition and being independent in eating and wheeling his wheelchair, R51 required assistance with dressing due to his medical conditions. The resident expressed that he was unaware of his exposure and relied on staff to tie his gown or provide a second gown for coverage. Interviews with facility staff, including a CNA, a licensed nurse, and an administrative nurse, confirmed that residents should have their backsides covered, especially in communal areas like the dining room. The facility's dignity policy emphasized the importance of maintaining residents' dignity by ensuring they are dressed appropriately and that hospital gowns should only be used if specifically requested and documented in the care plan. The failure to adhere to this policy resulted in a deficiency that compromised R51's dignity and psychosocial well-being.
Failure to Provide Timely Written Notification of Transfer
Penalty
Summary
The facility failed to provide timely written notification of transfer to a resident, identified as R238, or their representative for several facility-initiated transfers. The resident's electronic medical record documented multiple unplanned discharges to a short-term acute hospital with a return anticipated, yet there was no evidence of written notification for these transfers on specific dates. The resident had a history of neuromuscular dysfunction of the bladder, congestive heart failure, and paraplegia, and was dependent on staff for functional abilities such as bathing, toileting, and dressing. Despite having intact cognition, as indicated by a BIMS score of 14, the resident's clinical record lacked documentation of the required written notifications for transfers. Interviews with facility staff revealed that the responsibility for ensuring written notification of transfer and bed hold completion before a resident's transfer lay with the nurses. However, the administrative nurse was unable to find any record of the written notifications for the resident's transfers prior to a specific discharge date. The facility's bed hold policy, revised in April 2023, required written notification to be provided to the resident or their representative before a transfer, or within 24 hours in case of an emergency, but this was not adhered to in the case of R238.
Failure to Update Dialysis Care Plan for Resident
Penalty
Summary
The facility failed to revise the care plan for a resident, identified as R62, to include necessary interventions for her dialysis access site. R62, who has end-stage renal disease and relies on dialysis, had a left arteriovenous (AV) fistula placed in December 2023. Despite this significant change, the care plan did not include directions for monitoring the AV fistula, such as assessing for a thrill or bruit, or restrictions on using the affected extremity for blood pressure measurements. The lack of updated care plan interventions was confirmed through observations, record reviews, and staff interviews. The deficiency was identified during a survey where it was noted that the facility's care plan policy required updates at least every 90 days or with significant changes in the resident's condition. However, the policy lacked specific directions for revising care plans. Interviews with staff revealed that the oversight was unintentional, and the care plan had not been updated to reflect the resident's current dialysis access needs. This oversight placed the resident at risk for impaired care due to uncommunicated care needs.
Deficiency in Suprapubic Catheter Management
Penalty
Summary
The facility failed to ensure proper care for a resident with a suprapubic catheter, leading to a deficiency in catheter management. The resident, identified as R12, had a history of chronic kidney disease, malignant neoplasm of the prostate, and bladder dysfunction. Despite having an indwelling catheter and being treated for a urinary tract infection, the care plan lacked specific instructions for anchoring the catheter to prevent pulling or injury. Observations revealed that the catheter was anchored on the resident's left thigh, contrary to the resident's previous experience of having it anchored on the abdomen. This improper anchoring resulted in the catheter tubing being tinged with white mucous and bright red blood, indicating potential complications. Interviews with facility staff, including a CNA and a licensed nurse, highlighted a lack of clarity and knowledge regarding the appropriate placement of the catheter anchor for a suprapubic catheter. The CNA was unsure of the correct placement, and the licensed nurse suggested that the anchor should be placed according to the resident's preference, which was not documented in the care plan. The administrative nurse stated that the facility followed the manufacturer's instructions, which allowed for placement on the abdomen or upper thigh, but did not believe this needed to be included in the care plan. This lack of specific guidance and adherence to standard practices placed the resident at risk for catheter-related complications.
Failure in Dialysis Care Communication and Monitoring
Penalty
Summary
The facility failed to ensure ongoing communication and collaboration with the dialysis facility regarding a resident's health status with each dialysis procedure. The resident, who had end-stage renal disease and required dialysis, had a care plan that directed staff to monitor and report any signs of infection or complications at the dialysis access site. However, the care plan lacked specific directions related to the resident's dialysis fistula, such as assessing for a thrill or bruit and restrictions for the extremity. Additionally, the facility did not maintain documentation of monitoring the resident's AV fistula shunt access site for a thrill or bruit from December 2023 to August 2024. The facility was unable to provide dialysis communication forms for the resident from December 2023 to June 2024, indicating a lack of proper communication with the dialysis center. The resident reported that while communication sheets were sent with her to dialysis, they were not always returned. An administrative nurse acknowledged the oversight in updating the resident's orders to reflect the presence of the AV fistula, which resulted in the fistula not being monitored as required. This deficiency placed the resident at risk for complications related to dialysis.
Failure to Assess Bed Rail Risks with Low Air-Loss Mattress
Penalty
Summary
The facility failed to properly assess the risks associated with the use of bed rails for a resident, identified as R73, who was using a low air-loss mattress. Despite the presence of a right-sided assist bar on the resident's bed, the evaluations conducted did not address or acknowledge the potential risks associated with the combination of the assist bar and the low air-loss mattress. The resident's medical records indicated severe cognitive impairment and significant physical limitations, requiring extensive assistance with activities of daily living. However, the care plan lacked documentation regarding the use of bed rails or assistive positioning devices, and the evaluations failed to consider the specific risks posed by the low air-loss mattress. Observations and interviews revealed that the facility's staff did not consistently monitor or assess the safety of the bed rails in conjunction with the low air-loss mattress. A licensed nurse admitted uncertainty about the frequency of checks and whether the mattress was included in the assessments. The administrative nurse confirmed that device assessments should include the use of low air-loss mattresses, but documentation for R73 was lacking. The facility's policy required appropriate assessment for the risk of entrapment and adherence to manufacturer's recommendations, yet these procedures were not followed, placing the resident at risk for impaired safety.
Failure to Document PRN Psychotropic Medication Stop Date
Penalty
Summary
The facility failed to ensure that a resident's as-needed (PRN) hydroxyzine, a psychotropic medication, had a 14-day stop date or documentation of a physician's rationale and specific duration of use. This oversight was identified during a review of the resident's electronic medical records, which revealed an active order for hydroxyzine without a stop date. The facility was unable to provide the necessary documentation for the continuation of the medication past the required 14-day stop date when requested by surveyors. The resident involved had a medical history that included hypertension, congestive heart failure, type two diabetes mellitus, and morbid obesity. The resident's admission data indicated intact cognition and no behavioral symptoms, although he was taking an antianxiety medication. Observations and interviews with the resident and facility staff confirmed the lack of appropriate documentation for the PRN medication. The facility's policy required that PRN psychotropic medications include a stop date or documented physician guidance for extended use, which was not adhered to in this case.
Failure to Secure Hazardous Materials
Penalty
Summary
The facility failed to secure hazardous materials when a Sharps container on a medication cart was found overfilled past the fill line, with lancets resting on top and accessible. This was observed during a walkthrough of the fourth-floor hallway. Later, the contents of the Sharps bin overflowed onto the floor and were picked up by an unidentified staff member using their bare hands, who then shoved the contents back into the bin and left the area. The medication cart was eventually removed from the area. Licensed Nurse G confirmed that nursing staff should replace Sharps bins before they reach the full mark and should never attempt to push or reach inside the bins due to the risk of being stuck by hazardous materials. Administrator A stated that staff were expected to replace the Sharps bins or notify maintenance instead of allowing the bins to overflow. A review of the facility's Injection Safety and Sharps Injury Protection Plan indicated that bins were to be changed out frequently and never allowed to be filled past the full mark, and staff should never attempt to push down materials into the bins. This deficient practice placed four cognitively impaired, independently mobile residents at risk for preventable injuries and accidents.
Sanitary Dietary Standards Not Followed
Penalty
Summary
The facility failed to follow sanitary dietary standards for food storage and maintaining a sanitary food service environment. During an inspection of the fourth-floor kitchenette, surveyors found old food particles and debris in the microwave, food debris and stains in the condiment food chiller, and old coffee and stains in the coffee pot and machine. Additionally, an ice chest contained warm stale-smelling water, and the refrigerator had dried food stains with no evidence of temperature assessments. The storage cabinets contained brown-stained towels and an uncovered food thermometer touching dirty surfaces. The ice machine had calcium-encrusted stains on the ice outlets. On the third floor, the refrigerator temperature log had not been checked recently, and the refrigerator contained expired thickened juices, an undated sandwich and pie, and undated packages of cookie dough in the freezer. The condiment food chiller had an undated small carton of milk, and the cabinets contained a stained hospital blanket and a portable griddle placed face down on dirty surfaces. Cups labeled with residents' names were stored face down in soiled cabinets. The ice machine also had calcium-encrusted stains. Dietary staff stated that the kitchenettes should be managed by contracted dining services, and facility staff were expected to clean up minor spills, inspect food daily, and ensure open food was labeled and dated. However, these practices were not followed, leading to the identified deficiencies.
Failure to Adequately Address Behavioral Health Needs
Penalty
Summary
The facility failed to adequately meet the behavioral health needs of a resident (R1) with diagnoses of major depressive disorder, Alzheimer's disease, and bipolar disorder. Despite having a care plan in place that included non-pharmacological interventions, the facility did not effectively implement these strategies, resulting in repeated behavioral episodes. R1 exhibited verbal and physical aggression towards other residents and staff on multiple occasions, including incidents where R1 verbally threatened and physically scratched another resident (R2) and aggressively kicked a different resident (R3). The care plan lacked specific details on the non-pharmacological interventions used during these episodes, and there were instances where no de-escalation techniques were documented or attempted during behavioral outbursts. The facility's records indicated that R1 had a history of behavioral issues, including verbal aggression and physical aggression, which were documented in various incident reports. Despite these documented behaviors, the facility's interventions were inconsistent and insufficient. For example, after an incident of verbal aggression towards R2, R1 was temporarily placed on 15-minute checks, but the care plan did not detail specific non-pharmacological interventions. Additionally, during an episode where R1 chased and attempted to hit a nurse, the progress note failed to document any de-escalation attempts or notification to the medical provider. Interviews with facility staff revealed that they were aware of R1's behavioral triggers and the need for non-pharmacological interventions, such as distraction techniques and environmental changes. However, these strategies were not consistently applied or documented in R1's care plan. The facility's Behavioral Management policy emphasized a person-centered approach and the need for individualized interventions, but the facility did not adhere to this policy, resulting in repeated behavioral episodes and placing R1 and other residents at risk for harm.
Latest citations in Kansas
Surveyors found that the facility failed to maintain sanitary food storage, handling, and dishwashing practices in the kitchen. Clean dishes were stored upright instead of inverted, and numerous food items in coolers, freezer, pantry, and spice racks were undated, missing the year, had unreadable dates, or showed visible mold, while some bags and containers were left open or unsealed. A dietary staff member handled ready-to-eat foods such as bread and butter with bare hands and repeatedly washed hands with water only, without soap or sanitizer, while preparing pureed meals for a resident. The low-heat dish machine repeatedly operated below the facility’s stated minimum wash temperature, as documented on the temperature log. These practices were inconsistent with the facility’s own food storage policy and staff’s stated expectations for glove use, labeling, sealing of food, dish storage, and dishwashing temperatures.
The facility did not employ a full-time Certified Dietary Manager (CDM) as required by its own Nutritional Services Policy, despite serving meals to 31 residents. A dietary staff member without CDM credentials was observed overseeing meal preparation, and both this staff member and an administrative nurse confirmed that the staff member was not certified, although enrolled in CDM classes. The policy specified that a CDM must oversee key functions such as menu planning, diet and diet manual with nutritional evaluations, office procedures for notifying the RD of new elders, food production, and food service, but no certified individual was fulfilling these responsibilities.
Surveyors found that the facility failed to follow professional standards for food storage and temperature monitoring. A freezer had significant ice buildup, and a refrigerator contained unlabeled, undated sliced cheese. Temperature logs for multiple freezers and refrigerators were incomplete over several days, despite policy requiring routine monitoring and documentation. The ice machine area contained extraneous items, including a plastic lid, a metal object on the floor, and a cup on the drain. In dry storage, several open food items, including pasta, noodles, gelatin, and pancake mix, were undated, unlabeled, or unsealed. Dietary staff confirmed these conditions, and the Dietary Manager later described expectations that all food be labeled, dated, and properly sealed per facility policy.
Surveyors found that staff did not consistently follow EBP, hand hygiene, and clean laundry handling practices. During tracheostomy care for a resident, a nurse wore gloves and a mask but did not don a gown or change gloves before placing clean gauze and the trach cannula. In a separate case, after completing wound care for another resident, the same nurse manipulated a suprapubic catheter tubing while still holding wound supplies and then left the room without performing hand hygiene. Additionally, a housekeeping/laundry staff member removed residents’ personal items from a covered cart and carried them over the shoulder between halls without keeping the items covered. These actions did not follow facility policies requiring targeted gown and glove use for high-contact care, proper hand hygiene around invasive devices and dressings, and keeping laundry carts covered between rooms.
A resident with hemiparesis, chronic osteomyelitis, and intervertebral disc disorder with radiculopathy experienced a fall in his room, was found on the floor near a heater with pain and bruising, and was later confirmed by mobile X-ray to have a nondisplaced fracture of the left superior pubic ramus. Despite this, the subsequent quarterly MDS documented no falls since the prior assessment and did not code the event as a fall with major injury, even though the care plan and progress notes described the fall and resulting fracture. An administrative nurse later acknowledged that the falls section of the MDS had been coded in error, contrary to facility policy and RAI manual requirements for accurate resident assessment.
A resident with severe morbid obesity, vascular dementia, anxiety, and a history of falls, but intact cognition per BIMS, was repeatedly assisted in a wheelchair by staff without foot pedals in place. On multiple observed occasions, staff pushed and turned the resident in the wheelchair while the resident held his feet off the floor and a sock was seen dragging on the floor. Interviews showed staff uncertainty and inconsistency regarding the requirement for foot pedals when assisting the resident, despite the resident’s documented fall risk and a facility falls policy requiring interventions to reduce fall risk.
A resident with Alzheimer’s disease, CKD, BPH, obstructive uropathy, and urinary retention had a suprapubic catheter that staff repeatedly secured incorrectly. During catheter care, two nurses cleaned the abdominal insertion site but attached the Stat-lock to the resident’s thigh, anchoring the tubing to the leg instead of the abdomen. Nursing leadership stated they expected leg anchoring and noted the catheter policy did not specify Stat-lock placement, even though the facility’s suprapubic catheter competency checklist explicitly directed that the tubing be secured to the abdomen.
A resident with dementia, severe cognitive impairment, and depression experienced unplanned weight loss after the RD documented a slow weight-loss trend and recommended house supplement shakes TID with added calories to meals. The facility entered and carried out the supplement order only once daily, and staff confirmed the resident received a shake only on second shift. Weight documentation showed a large, unverified increase followed by a re-weigh that demonstrated a 3.16% loss over a short period, and nursing staff did not promptly recognize or recheck the significant weight discrepancy. The RD was not informed that her TID recommendation had been effectively reduced to once daily, and the facility’s own weight-loss prevention processes were not followed.
A resident with chronic respiratory failure, a tracheostomy, and oxygen therapy orders did not have an Ambu bag or emergency tracheostomy kit readily available at the bedside, despite care plan directives for respiratory care, suctioning, and emergency response if the tracheostomy tube came out. Surveyors observed on multiple occasions that only oxygen and suction were present in the room, while the Ambu bag and emergency supplies were stored on a covered cart in the hallway under a Hoyer lift, requiring movement of equipment before use. Staff, including CNAs, an LN, and an administrative nurse, confirmed that emergency tracheostomy supplies were kept in the hallway or medication room and not at the bedside, and that they were instructed to call 911 rather than attempt reinsertion of the tracheostomy tube, even though the facility’s respiratory care policy required services in accordance with professional standards and the resident’s care plan.
A resident with diabetes, heart failure, muscle weakness, severe cognitive impairment, incontinence, and limited mobility was identified as at risk for pressure ulcers, with care plans calling for turning/repositioning, use of a pressure-reducing device, and extensive staff assistance for ADLs. Despite these documented risks and interventions, the resident, who preferred to remain in a recliner or wheelchair and became less mobile after a foot fracture requiring a walking boot, developed a facility-acquired Stage 2 pressure ulcer on the buttocks. Wound assessments showed the ulcer’s presence and progression over time, indicating that timely and effective preventive measures were not implemented in accordance with the facility’s wound assessment and prevention policy.
Unsanitary Food Storage, Handling, and Dishwashing Practices in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to maintain sanitary conditions for food storage and preparation in the kitchen. During an initial kitchen tour, they observed multiple clean containers and plates on the drying rack not inverted, leaving eating surfaces exposed. Numerous food items in the kitchen cooler, walk-in cooler, freezer, pantry, and spice rack were either undated, missing the year, had unreadable dates, or were past labeled use-by dates. Examples included cheese and ham slices with only month and day, multiple large containers of sauces, dressings, olives, cherries with visible black mold on the rim and lid, parmesan cheese, syrups, soy sauce, wing sauce, and green beans all lacking complete or legible dating. Additional findings included rusted and peeling cooler racks, open and unsealed bags of frozen foods and pantry items, and a rice bin with a handwritten prep date missing the year. Further observations showed improper food handling and hand hygiene practices by dietary staff. One dietary staff member handled ready-to-eat foods, including butter and bread for toast, with bare hands and then placed the toast on a tray for a resident. On another occasion, a partially wrapped package of cheese slices in the cooler was found without any date. The same dietary staff member was observed washing hands under running water without using soap or sanitizer on three separate occasions while pureeing food for lunch. The facility did not provide a hand hygiene policy specific to dietary staff when requested. Surveyors also reviewed the operation of the low-heat Ecolab dishwasher and its temperature logs. At the time of observation, the wash temperature was 102°F, and the April temperature log showed multiple days with wash temperatures below the documented minimum of 120°F at which the supervisor should be notified. Administrative and dietary staff later confirmed that gloves should be worn when handling ready-to-eat foods, all stored food should be sealed and labeled with month, day, and year, dishes should be inverted, and the dishwasher wash cycle should be at least 120°F. The facility’s existing Food Storage policy required staff to label all food items with the name and date opened or use-by date and to discard food past expiration, but survey findings showed these practices were not consistently followed in the kitchen.
Lack of Certified Dietary Manager Overseeing Food and Nutrition Services
Penalty
Summary
The facility failed to employ a full-time certified dietary manager (CDM) to oversee food and nutrition services for 31 residents receiving meals from the facility kitchen. On one observed noon meal, the menu consisted of shrimp, cornbread, cooked sliced squash, rice, and yellow cake with chocolate frosting, and dietary staff member BB was observed overseeing preparation of this meal in the kitchen. During an interview, dietary staff BB confirmed she was not a CDM, stating she had enrolled in but not completed the certification classes. Administrative Nurse D also verified that dietary staff BB did not have dietary manager certification, although she had started the dietary certification classes. The facility’s Nutritional Services Policy, revised 01/21/26, documented that a certified dietary manager would oversee all kitchen procedures, including menu planning, diets and the diet manual with nutritional evaluations, office procedures related to notifying the Registered Dietitian of new elders, food production, and food service, but no such certified individual was in place at the time of the survey.
Failure to Properly Label, Store, and Monitor Food and Equipment Temperatures
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage, distribution, and service practices based on observations, record review, and staff interviews. In the kitchen, a white upright freezer had approximately one-quarter inch of ice buildup along the inside and shelves, and the kitchen refrigerator contained a plastic bag of sliced yellow cheese that was unlabeled and undated. Review of March temperature logs showed missing morning and evening temperature documentation for multiple units, including a chest freezer in dry storage on numerous dates, a white stand-up freezer on several dates, a double-door refrigerator on several dates, and a single-door refrigerator on multiple dates. April logs also lacked documentation of readings for a double-door freezer on specified dates. The facility’s policies required that frozen foods be stored at 0 to -10°F, produce at 38-44°F, dairy at 35-40°F, and that temperature logs be completed and monitored by the Certified Dietary Manager or designee. Additional observations showed sanitation and labeling issues in and around the kitchen and dry storage areas. The ice machine between the kitchen and storage room had a plastic lid and a metal object on the floor behind it, and a plastic green drinking cup sitting on top of the drain underneath it. Eight 15.5-lb plastic jugs of used cooking grease were observed with numerous grayish-black substances on their tops. In dry storage, surveyors found an approximately one-quarter full 5-lb package of undated pasta Labello egg noodles, an approximately one-quarter full 4.5-lb package of unlabeled, undated, unsealed noodles, approximately three-quarters of a full package of undated strawberry gelatin, and an approximately three-quarters full bag of unsealed buttermilk pancake mix. A dietary staff member verified these findings during the survey, and the Dietary Manager later stated that staff were expected to label and date all food placed in dry storage, refrigerators, or freezers when received and when opened, and ensure items were sealed, labeled, and dated with the open date, as outlined in the facility’s written policies.
Failure to Follow Enhanced Barrier Precautions, Hand Hygiene, and Laundry Handling Practices
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective infection prevention and control program, specifically related to Enhanced Barrier Precautions (EBP), hand hygiene, and handling of clean laundry. During tracheostomy care for Resident 2, a licensed nurse performed hand hygiene, donned gloves, and wore a mask but did not don a gown as required under EBP and did not change gloves before placing clean gauze or the tracheostomy cannula. In a separate wound care observation for Resident 6, the same nurse performed hand hygiene and applied a gown and gloves before care, but after completing the wound care and while holding gauze and wound cleanser, the nurse inspected and manipulated the resident’s suprapubic catheter tubing and then left the room without performing hand hygiene. Additional deficiencies were observed in the handling of clean laundry. A housekeeping/laundry staff member placed a covered cart with residents’ personal items in one hall, then removed items from the cart and carried them over the shoulder to another hall without using the cart and without keeping the items covered between rooms. Interviews with nursing and administrative staff confirmed that wound care supplies should be kept in residents’ rooms or bagged and taken to the wound nurse, that hand sanitizing should be performed before and after wound care and after contact with catheters or tubing, and that staff are expected to wear gown, gloves, and mask at minimum for EBP. The housekeeping supervisor also stated that laundry staff are expected to keep the cart covered between rooms. These practices did not align with the facility’s written policies on EBP and hand hygiene, which require targeted gown and glove use during high-contact care and hand cleansing before and after resident contact, after contact with blood or body fluids, after removing PPE, and before procedures involving invasive devices or dressing care.
Inaccurate MDS Coding of Fall With Major Injury
Penalty
Summary
The deficiency involves the facility’s failure to accurately complete the Minimum Data Set (MDS) assessment for Resident 13, resulting in an incorrect coding of the resident’s fall history and injury status. Resident 13’s electronic medical record documented multiple diagnoses, including hemiparesis/hemiplegia, chronic osteomyelitis, and intervertebral disc disorder with radiculopathy. The quarterly MDS dated 03/24/26 recorded a Brief Interview for Mental Status (BIMS) score of 15, indicated the resident required supervision for walking 10 feet and partial assistance for walking 50 feet, and documented that the resident had no falls since the previous MDS assessment. However, this conflicted with clinical documentation and the resident’s care plan and progress notes. On 01/16/26, progress notes showed that staff responded to the resident’s call light and found him on the floor next to his heater, lying on boxes, papers, and his bedside table. The resident complained of back and left hip pain, had swelling behind his left ear from hitting the heater, redness on his left cheek, and reported tenderness with weight-bearing on his leg. A mobile X-ray later confirmed a nondisplaced fracture of the left superior pubic ramus, and the provider assessed the resident the same day. The care plan documented that the resident continued to act independently despite education to use the call light, and the resident later reported to therapy staff that he had falls and was working to get stronger after his last fall. During interviews, an administrative nurse acknowledged that the resident had a fall resulting in a hip fracture that should have been coded on the MDS as a fall with major injury, and that the falls section of the MDS had been coded in error, contrary to the facility’s policy to complete the MDS according to federal regulations and the RAI manual.
Failure to Use Wheelchair Foot Pedals When Assisting a Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide an environment free of accident hazards by not ensuring the use of wheelchair foot pedals when staff assisted a resident in a wheelchair. The resident had diagnoses including severe morbid obesity, vascular dementia, anxiety, and noncompliance, and had a BIMS score of 15 on multiple MDS assessments, indicating intact cognition. The resident’s assessments and Falls Care Area Assessment documented a history of falls within the previous months and identified the resident as being at risk for falls. The care plan documented that the resident was at risk for falls, had experienced a fall, and that his back locked up at times requiring the use of a wheelchair. On one observed occasion, a CNA pushed the resident in a wheelchair without foot pedals attached as he was brought from outside smoking back to his room, during which the resident crossed and held his feet off the floor. On another observed occasion, a nurse turned the resident in his wheelchair and assisted him to the dining room without foot pedals, during which the resident’s sock was half off and dragged on the floor, and the resident again held his foot off the floor. During interviews, one nurse expressed uncertainty about whether the resident should be assisted in the wheelchair without foot pedals, while a CMA stated the resident used foot pedals when being assisted but not when self-propelling. Administrative nursing staff confirmed that staff should not assist the resident in the wheelchair without foot pedals. The facility’s falls policy stated that residents would be assessed for fall risks and interventions implemented to reduce those risks.
Improper Securing of Suprapubic Catheter Tubing
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate care and treatment for a resident with a suprapubic catheter by not securing the catheter tubing according to current standards of practice and the facility’s own competency checklist. The resident had multiple urologic and cognitive conditions, including Alzheimer’s disease with severely impaired cognition (BIMS score of four), chronic kidney disease stage three, benign prostatic hyperplasia, obstructive uropathy, and urinary retention, and was documented as having an indwelling catheter. The care plan included an order from the resident’s urologist directing staff not to remove the catheter and directed staff to apply Skin-prep prior to attaching a Stat-lock for the suprapubic catheter. On two separate observations, licensed nurses assessed and cleaned the suprapubic catheter site on the resident’s abdomen but attached the Stat-lock to the resident’s left upper thigh, securing the tubing from the abdomen to the leg. One nurse confirmed the Stat-lock was attached to the thigh and stated they were unaware that a Stat-lock could be adhered to the abdomen. The administrative nurse stated she expected the Stat-lock to be anchored to the leg and acknowledged that the facility catheter policy did not specify Stat-lock placement for a suprapubic catheter. However, she also stated that the facility’s suprapubic catheter replacement competency checklist, which she had previously reviewed, directed that the catheter tubing should be anchored to the abdomen. The competency checklist documented that the catheter tubing should be secured to the abdomen, but this was not followed in practice.
Failure to Implement Dietitian’s TID Supplement Order and Validate Significant Weight Changes
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate nutritional maintenance for Resident 27 by not implementing the registered dietitian’s recommendation for house supplement shakes three times daily and by not appropriately monitoring and validating significant weight changes. Resident 27 had dementia with severe cognitive impairment, chronic pain, unspecified intellectual disabilities, and major depressive disorder, used a wheelchair, and required set-up or clean-up assistance for eating. The MDS documented a weight of 123 lbs with no weight loss or gain at that time, and the care plan included nutrition-focused interventions such as providing diet as ordered, snacks between meals, monitoring for loss of appetite while on Remeron, and providing supplements as ordered. On 03/03/26, the dietitian documented that the resident had slow, unplanned weight loss related to a decline in energy and recommended offering a house supplement three times a day and adding extra sugar, cream, and butter to foods and fluids to increase energy intake and promote weight stability. Despite this recommendation, the electronic task list from 03/16/26 to 04/13/26 showed the resident was only offered and received a supplement drink once daily in the afternoon. Staff interviews confirmed that the resident received a supplement only on second shift around 2:00 PM, and an administrative nurse acknowledged she had missed the dietitian’s TID recommendation and entered the order for only once daily. Weight records showed a documented weight of 123.4 lbs on 04/01/26 and an implausible weight of 168.0 lbs on 04/10/26, which was not recognized or rechecked at the time by nursing staff. A subsequent re-weigh on 04/15/26, using the wheelchair tare method, yielded a resident weight of 119.5 lbs, reflecting a 3.9 lb (3.16%) loss from 04/01/26. Administrative staff later stated that the 168 lb weight should have been immediately reported and rechecked, and that whoever weighed the resident should have reviewed the previous weight and performed a re-weight if there was a significant change. The facility’s weight loss prevention policy required nutritional interventions and RD consultation for residents with poor or declining intake or weight loss, but the RD was not informed that her TID supplement recommendation had been effectively reduced to once daily.
Emergency Tracheostomy Equipment Not Readily Available at Bedside
Penalty
Summary
The deficiency involves the facility’s failure to ensure that emergency respiratory equipment, specifically an Ambu bag, was readily available at the bedside for a resident with a tracheostomy in the event of accidental extubation or respiratory distress. The resident had diagnoses including sleep apnea, chronic respiratory failure with hypoxia, obesity, dysphagia, malignant neoplasm of the nasopharynx, and required oxygen therapy and tracheostomy care. The resident was cognitively intact, used a wheelchair, and required varying levels of assistance with ADLs. The care plan documented that the resident received breathing treatments, required staff reminders to notify them when treatments were finished, and that staff were to provide oxygen via tracheostomy mask and suction as indicated. The care plan and physician orders also directed staff to call 911 and send the resident to the ER if the entire tracheostomy tube came out, and to follow the facility’s Emergency Protocol Health policy. Surveyor observations on multiple occasions showed that while oxygen and suction were available at the bedside, there was no Ambu bag in the resident’s room. Instead, the Ambu bag and emergency supplies were stored on a covered cart in the hallway under a Hoyer lift, with a battery charger on top, requiring staff to move equipment and wheel the cart into the room before use. Staff interviews confirmed that the emergency tracheostomy supplies and Ambu bag were not kept at the bedside and were instead located in the hallway or medication room. Nursing staff stated that all nurses were CPR-qualified and that hospice residents with tracheostomies had bedside emergency kits because hospice provided them. An administrative nurse reported that tracheostomy care competencies were done annually and explained that there was no emergency kit or Ambu bag at the bedside because the physician had instructed staff not to reinsert the tracheostomy if it came out, but to call 911 immediately. The facility’s Respiratory Care policy stated that necessary respiratory care and services would be provided in accordance with professional standards of practice, the resident’s care plan, and resident choice.
Failure to Implement Timely Interventions to Prevent Facility-Acquired Pressure Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to initiate timely and adequate interventions to prevent the development and progression of a pressure ulcer for Resident 27, who was identified as at risk for pressure ulcer development. The resident had multiple diagnoses including diabetes mellitus, osteoarthritis, heart failure, and muscle weakness, and had a BIMS score of five indicating severely impaired cognition. Assessments documented that the resident required extensive assistance of one to two staff for bed mobility, personal hygiene, dressing, repositioning, and transfers, and that she had a urinary catheter for constant urinary retention and incontinence. The MDS and care plans identified the resident as at risk for skin impairment, with a history of refusing to lie down to relieve pressure from the buttocks, and indicated she was on a turning/repositioning program with nutritional or hydration interventions and a pressure-reducing device in her chair. A Braden Scale score of 16 further indicated risk for pressure ulcer development. Despite these identified risks and care plan directives, the resident developed a facility-acquired Stage 2 pressure ulcer on the left buttocks. Weekly wound assessments documented the presence and progression of an open area on the left buttocks, with measurements changing over time, including a lateral opening measuring 2.0 cm by 1.0 cm and later a left inner buttocks wound measuring 3.0 cm by 2.0 cm by 0.5 cm depth, and then 2.0 cm by 3.5 cm by 0.8 cm depth. The record noted that the resident became less mobile after sustaining a left 5th metatarsal fracture requiring a walking boot, and that she was incontinent and preferred to sit in a recliner and wheelchair rather than sleep in bed. The facility’s own Wound Assessment, Prevention and Treatment policy required timely skin assessments, Braden evaluations, and immediate implementation of plans to reduce pressure ulcer risk, but the development of a facility-acquired pressure ulcer under these known risk conditions demonstrated that timely preventive interventions were not effectively implemented.
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