Life Care Center Of Andover
Inspection history, citations, penalties and survey trends for this long-term care facility in Andover, Kansas.
- Location
- 621 W 21st, Andover, Kansas 67002
- CMS Provider Number
- 175157
- Inspections on file
- 28
- Latest survey
- November 17, 2025
- Citations (last 12 mo.)
- 3 (3 serious)
Citation history
Health deficiencies cited at Life Care Center Of Andover during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and behavioral issues was subjected to physical and verbal abuse by an LPN, who responded to the resident's aggression with threats, physical restraint, and inappropriate handling. The incident was witnessed by a CNA but not reported until the following day, allowing the LPN to continue providing care to the resident and others without restriction. The facility failed to immediately remove the LPN from resident care after the abuse occurred.
A resident with severe cognitive impairment and a history of aggressive behaviors became agitated and physically aggressive toward a nurse, who responded by yelling, threatening harm, and using a neck restraint. The incident was witnessed by a CNA who did not report it until the following day. The nurse had not received formal dementia training, and the response did not follow the resident's care plan or facility policy, resulting in immediate jeopardy.
A resident with severe cognitive impairment and behavioral issues was subjected to staff-to-resident abuse by an LPN, who responded to the resident's aggression with threats, physical restraint, and inappropriate handling. The incident was witnessed by a CNA, but was not reported to administration until the following day, violating facility policy requiring immediate reporting of suspected abuse and resulting in immediate jeopardy.
A resident with severe cognitive impairment and chronic pain experienced uncontrolled crying, poor oral intake, and visible distress over several days, but staff failed to consistently assess, document, or manage the pain effectively. Despite orders for scheduled and as-needed pain medications, there were lapses in medication administration, inadequate follow-up when pain relief was ineffective, and poor communication among staff and providers. The resident ultimately was found to have an acute fracture after days of ineffective pain relief.
Surveyors found that food items were not properly labeled or dated, plates were stored in a manner that could lead to contamination, and cleaning in dining areas was inadequate. Additionally, hazardous chemicals were improperly stored in a dining room cabinet. These actions did not follow the facility's food safety policy and placed residents at risk for food safety concerns.
A CNA employed for over a year did not have a documented annual performance evaluation, as required. Administrative staff confirmed the absence of the evaluation and could not provide a policy regarding yearly performance reviews for staff.
Surveyors found that staff did not consistently elevate the head of the bed during tube feedings and failed to label and date enteral feeding bags for several residents with complex medical needs. Despite care plans and physician orders specifying protocols for safe enteral nutrition, these were not followed, and the facility could not provide a policy on enteral nutrition when requested.
Several dependent residents did not receive consistent bathing and personal hygiene care as required, with documentation showing missed or irregular bathing opportunities, lack of evidence that care was offered or refused, and observations of poor hygiene. Staff interviews confirmed that scheduled baths were sometimes missed due to staffing issues or resident behaviors, and care plans lacked clear direction or follow-through on resident preferences.
Surveyors found that linen carts and pillows were left uncovered, bedspreads were improperly stored, and medical equipment such as urinary catheter bags and CPAP machines were not maintained in a sanitary manner. Staff failed to perform hand hygiene during wound care, catheter care, and feeding tube procedures, including not changing gloves between tasks. These actions were not in compliance with the facility's infection prevention policy.
A resident with PTSD, cognitive impairment, anxiety, dementia, and depression did not receive individualized, trauma-informed care as required. The care plan lacked trigger-specific interventions, and staff were unaware of the resident's PTSD diagnosis or effective strategies to prevent re-traumatization. The last trauma assessment was outdated, and the facility did not follow its own policy for regular evaluation and care planning.
Two residents at risk for pressure ulcers did not receive proper care when staff failed to set low air-loss mattresses according to actual weight and did not ensure the equipment was plugged in and functioning. One resident's mattress was set at the maximum weight rather than the resident's actual weight, while another resident's mattress was found unplugged and nonfunctional. Staff checks were inconsistent and did not always follow manufacturer or facility guidelines, resulting in inadequate pressure ulcer prevention.
A resident with severe cognitive impairment and spastic quadriplegic cerebral palsy was not provided with prescribed contracture prevention devices or a restorative nursing program, despite care plan directives. Observations showed the resident's hands were tightly clenched without palm grippers, and staff interviews indicated confusion about responsibility for applying these devices. Documentation did not reflect that the required interventions were implemented or monitored.
Staff did not provide timely incontinence care to a resident with dementia, resulting in a bladder incontinence episode in the dining room, and failed to ensure proper catheter bag positioning for another resident with severe cognitive impairment and an indwelling catheter. These actions were inconsistent with facility policies and placed residents at risk for negative outcomes.
Two residents experienced unmet care needs due to the facility's failure to provide appropriate bariatric equipment, ensure access to call lights, and use wheelchair foot pedals as required. One resident with morbid obesity did not have access to a suitable lift or wheelchair, resulting in missed weights and lack of proper bathing and transfers, while another resident with severe cognitive impairment was left without a reachable call light and was transported without foot pedals in place.
Two residents with complex medical and psychosocial needs did not have individualized, person-centered care plans addressing trauma-based care and meaningful activities. One resident with PTSD and severe cognitive impairment lacked trauma-informed interventions in the care plan, while another resident with quadriplegia and severe cognitive impairment had no documented activity participation or person-centered activities, despite staff awareness of his preferences.
Two residents' care plans were not updated to reflect critical changes in their care needs, including one resident's visitation restrictions after an aggressive incident with a family representative and another resident's need for new fall prevention interventions following multiple falls and a hip fracture. Staff and administrative interviews confirmed that these updates were not made, despite facility policy requiring timely care plan revisions by an interdisciplinary team.
A resident with severe cognitive and physical impairments, dependent on staff for ADLs and unable to use a standard push button call light, was not provided with the care plan-specified touch pad call light. Staff confirmed the resident could not operate the available device, and the appropriate equipment was not in place, leaving the resident unable to request assistance.
Two residents did not receive safe and appropriate respiratory care when their physician-ordered oxygen and CPAP equipment was not used or stored as directed. One resident with COPD and dementia was often observed without her nasal cannula in place and left it unbagged, while another resident on hospice had his CPAP mask left unsanitarily in the windowsill. Staff confirmed these practices did not follow facility policy for respiratory equipment storage.
A resident with PTSD and severe cognitive impairment did not have individualized, trigger-specific interventions in their care plan to prevent re-traumatization. Staff were unaware of the resident's PTSD diagnosis and related care needs, and the trauma-informed care assessment had not been updated since admission, contrary to facility policy.
Two residents using low air-loss mattresses did not receive safety assessments that addressed the specific risks of bed rail use with these mattresses. Both residents' records lacked documentation of risk assessments, informed consent, and education about potential hazards, despite facility policy requiring these steps. Staff interviews revealed uncertainty about proper assessment procedures, and observations showed improper equipment use and lack of resident or representative education.
The facility did not maintain or retain required daily nurse staffing data for the mandated period, with missing documentation for multiple dates, incomplete resident census records, and absent nursing hour totals. Administrative and front desk staff shared responsibility for posting and storing these records, but gaps in documentation were identified.
A resident with severe cognitive and physical impairments fell from their bed while receiving incontinence care, resulting in a scalp laceration requiring 13 staples. The CNA providing care was informed that the resident required only one-person assistance, contrary to the care plan's directive for one to two staff members. This lack of adherence to the care plan and facility policies on safety and supervision led to the preventable accident.
A resident with multiple diagnoses, including multiple sclerosis and paraplegia, fell and fractured her pelvis when a CNA attempted to transfer her alone using a mechanical lift, contrary to the facility's policy requiring two staff members for such transfers.
Failure to Protect Resident from Staff-to-Resident Abuse and Delay in Restricting Perpetrator Access
Penalty
Summary
A deficiency occurred when a licensed nurse engaged in staff-to-resident abuse involving a resident with severe cognitive impairment, traumatic brain injury, and a history of aggressive behaviors. The incident began when the resident exhibited escalating combative and aggressive behaviors, including grabbing the nurse's genitals and using obscene language. In response, the nurse yelled at the resident, grabbed his arm, threatened physical harm, and stated he would lock the resident in his room. The nurse further reported using a restraint technique involving grabbing the resident around the neck, which he described as a 'scare tactic.' A certified nurse aide witnessed the abuse but failed to report the incident to administrative staff until the following day. During this time, the nurse continued to have unrestricted access to the resident and other residents on the locked memory care unit. The facility did not immediately remove the nurse from resident care or restrict his access to vulnerable residents following the incident, contrary to facility policy and expectations for immediate response to allegations of abuse. The resident involved had a documented history of severe cognitive impairment, behavioral disturbances, and required specific interventions for agitation and aggression. Despite these known risk factors and care plan instructions for de-escalation, the nurse's actions escalated the situation and resulted in physical and verbal abuse. The facility's failure to act promptly to protect the resident and others from further potential abuse constituted a significant deficiency.
Removal Plan
- The Social Service Director/Designee interviewed all current in-house residents who were alert and oriented with an assessed BIMS score of 12 or higher to determine if they had experienced or witnessed misappropriation.
- The Regional Director of Clinical Services educated the Director of Nursing and the Executive Director on the incident of reportable event management and record review.
- The Director of Nursing/Designee reviewed behavior notes, progress notes, psychosocial notes, health status notes, event notes, and plan of care for all residents in the prior 14 days to audit for potential abuse-related events not previously investigated.
- The Director of Nursing/Designee initiated staff education on reporting of suspected Abuse, Neglect, and Exploitation, including misappropriation. Nursing Staff employees would have education provided prior to their next scheduled shift.
- The Director of Nursing/Designee initiated staff education on incident and reporting event management for interdisciplinary team (IDT), including Executive Director, Director of Nursing, Assistant Director of Nursing, Director of Rehabilitation, Social Service Director, Business Office Manager, Health Information Management, Activity Director, Dietary Manager, Infection Prevention, MDS Coordinator, and Admission. IDT would have education provided prior to working their next scheduled shift.
- The Director of Nursing/Designee would randomly ask five staff members what to do if Abuse, Neglect, or Exploitation (ANE), including injuries of unknown origin, was suspected five times weekly for four weeks, three times weekly for four weeks, and then randomly thereafter.
- The results of the above audits would be submitted to Quality Assurance and Performance Improvement (QAPI) Committee for further review and/or action, as well as any trends identified.
Staff-to-Resident Abuse and Delayed Reporting of Incident
Penalty
Summary
A resident with severe cognitive impairment, traumatic brain injury, and a history of aggressive behaviors exhibited escalating agitation and aggression, including yelling, cursing, and physical aggression toward staff. During an incident, the resident grabbed a licensed nurse's genitals and used obscene language. In response, the nurse yelled at the resident, grabbed his arm, threatened physical harm, and stated he would lock the resident in his room. The nurse also reported using a restraint technique involving grabbing the resident around the neck to prevent further aggressive behaviors. This interaction was witnessed by a certified nurse aide, who did not report the abuse to administrative staff until the following day. The resident's care plan instructed staff to intervene calmly before agitation escalated, to guide the resident away from distress, and to reapproach if the resident became aggressive. Staff were also directed to expect frequent use of profanity and to encourage appropriate language. Despite these care plan instructions, the nurse's actions during the incident included physical and verbal abuse, as well as the use of an unauthorized restraint technique. The nurse had not received formal dementia training since being hired, although he had attended a staff meeting that included behavioral management topics. The facility's policy required immediate reporting of any witnessed or alleged abuse, but the certified nurse aide who witnessed the event delayed reporting until her next shift. The facility's investigation confirmed the incident and noted the delay in reporting. The nurse involved was suspended and later terminated. The failure to protect the resident from staff-to-resident abuse and to ensure timely reporting of abuse constituted a deficiency and resulted in immediate jeopardy for the resident.
Removal Plan
- The Social Service Director/Designee interviewed all current in-house residents who were alert and oriented with an assessed BIMS score of 12 or higher to determine if they had experienced or witnessed misappropriation. No additional concerns were noted during the interviews.
- The Regional Director of Clinical Services educated the Director of Nursing and the Executive Director on the incident of reportable event management and record review.
- The Director of Nursing/Designee reviewed behavior notes, progress notes, psychosocial notes, health status notes, event notes, and plan of care for all residents in the prior 14 days to audit for potential abuse-related events not previously investigated.
- The Director of Nursing/Designee initiated staff education on reporting of suspected Abuse, Neglect, and Exploitation, including misappropriation. Nursing Staff employees would have education provided prior to their next scheduled shift.
- The Director of Nursing/Designee initiated staff education on incident and reporting event management for interdisciplinary team (IDT), including Executive Director, Director of Nursing, Assistant Director of Nursing, Director of Rehabilitation, Social Service Director, Business Office Manager, Health Information Management, Activity Director, Dietary Manager, Infection Prevention, MDS Coordinator, and Admission. IDT would have education provided prior to working their next scheduled shift.
- The Director of Nursing/Designee would randomly ask five staff members what to do if ANE, including injuries of unknown origin, was suspected five times weekly for four weeks, three times weekly for four weeks, and then randomly thereafter.
- The results of the above audits would be submitted to Quality Assurance and Performance Improvement (QAPI) Committee for further review and or action, as well as any trends identified.
Failure to Immediately Report Staff-to-Resident Abuse
Penalty
Summary
A deficiency occurred when a severely cognitively impaired resident with a history of traumatic brain injury and behavioral issues exhibited escalating combative and aggressive behaviors. During an incident, the resident grabbed a licensed nurse's genitals and used obscene language. In response, the nurse yelled at the resident, grabbed his arm, threatened physical harm, and stated he would lock the resident in his room. The nurse also reported using a restraint technique involving grabbing the resident around the neck to prevent further aggression. A certified nurse aide witnessed this staff-to-resident abuse. Despite witnessing the incident, the certified nurse aide did not immediately report the abuse to administrative staff as required by facility policy. Instead, the incident was reported the following day when the aide returned for her next shift. This delay in reporting meant that the facility administrator was not promptly informed of the abuse, which is a violation of the facility's abuse prevention policy that mandates immediate reporting of all alleged or suspected abuse. The failure to ensure immediate reporting of the abuse placed the resident in immediate jeopardy. The facility's own documentation and staff interviews confirmed that the incident was not reported in a timely manner, and that the required notification to administrative staff was delayed until the next day. This lapse in procedure directly contributed to the deficiency cited by surveyors.
Removal Plan
- The Social Service Director/Designee interviewed all current in-house residents who were alert and oriented with an assessed BIMS score of 12 or higher to determine if they had experienced or witnessed misappropriation. No additional concerns were noted during the interviews.
- The Regional Director of Clinical Services educated the Director of Nursing and the Executive Director on the incident of reportable event management and record review.
- The Director of Nursing/Designee reviewed behavior notes, progress notes, psychosocial notes, health status notes, event notes, and plan of care for all residents in the prior 14 days to audit for potential abuse-related events not previously investigated.
- The Director of Nursing/Designee initiated staff education on reporting of suspected Abuse, Neglect, and Exploitation, including misappropriation. Nursing Staff employees would have education provided prior to their next scheduled shift.
- The Director of Nursing/Designee initiated staff education on incident and reporting event management for interdisciplinary team (IDT), including Executive Director, Director of Nursing, Assistant Director of Nursing, Director of Rehabilitation, Social Service Director, Business Office Manager, Health Information Management, Activity Director, Dietary Manager, Infection Prevention, MDS Coordinator, and Admission. IDT would have education provided prior to working their next scheduled shift.
- The Director of Nursing/Designee would randomly ask five staff members what to do if ANE, including injuries of unknown origin, was suspected five times weekly for four weeks, three times weekly for four weeks, and then randomly thereafter.
- The results of the above audits would be submitted to Quality Assurance and Performance Improvement (QAPI) Committee for further review and or action, as well as any trends identified.
Failure to Assess and Manage Severe Pain in Cognitively Impaired Resident
Penalty
Summary
The facility failed to adequately assess and manage pain for a resident with severe cognitive impairment, chronic pain, and significant physical limitations. The resident had a history of osteoarthritis, hemiparesis, and chronic pain, and was dependent on staff for all activities of daily living. Despite care plan directives to evaluate pain interventions, provide both pharmacological and non-pharmacological pain relief, and notify the physician if interventions were ineffective, staff did not consistently follow these protocols. Documentation showed that the resident experienced episodes of uncontrolled crying, poor oral intake, and visible distress over several days, but there was a lack of follow-up assessment or timely action to address ongoing pain. The resident's medication orders included both scheduled and as-needed acetaminophen and hydrocodone-acetaminophen for pain management. However, when as-needed acetaminophen was found to be ineffective, there was no evidence that alternative pain management strategies were implemented or that the physician was promptly notified. Additionally, there was a lapse in the availability of the resident's scheduled hydrocodone-acetaminophen due to a delay in obtaining a new prescription, further contributing to inadequate pain control. Communication between nurses, physicians, and other healthcare providers regarding the resident's pain was insufficient, as critical information was not consistently documented in the electronic health record or the Team Health Book. Staff interviews revealed that while some aides reported the resident's pain to nurses, and nurses were aware of increased pain, documentation and follow-up actions were inconsistent or lacking. The resident's pain assessments on the treatment administration record often indicated no pain, despite clear behavioral signs and staff observations of distress. Ultimately, the resident was found to have an acute, displaced fracture of the left humerus, which had not been identified on earlier X-rays, and had experienced ineffective pain relief for six days prior to the diagnosis. The facility's failure to assess, document, and manage the resident's pain according to professional standards and the care plan resulted in prolonged suffering and placed the resident at risk for further decline.
Deficient Food Storage, Preparation, and Sanitation Practices
Penalty
Summary
Surveyors identified multiple failures in the facility's dietary services related to food storage, preparation, and meal service. During an inspection of the kitchen, four large plastic bins containing various cereals were found without dates indicating when they were opened. Additionally, plates were stored facing upward on a mobile counter without any barrier to prevent contamination of the eating surfaces. In the main dining room, trash and food debris were observed under the ice machine and condiment counter, indicating inadequate cleaning practices. Further inspection of the 500 hall dining room revealed a bottle of drain cleaner stored in a cabinet under the sink, despite the product's warning label indicating it was hazardous and should be kept out of reach of children. Dietary staff confirmed that all food items were expected to be labeled and dated, and that plates and utensils should be stored downward to prevent contamination. The facility's Food Safety policy required safe and sanitary practices for food storage, preparation, and service, and specified that the kitchen should be maintained in a sanitary manner.
Failure to Complete Yearly Performance Evaluation for CNA
Penalty
Summary
The facility failed to complete a yearly performance evaluation for one of five Certified Nurse Aides (CNA) reviewed, despite the CNA being employed for over 12 months. Record review showed that CNA O, hired on 06/13/23, did not have a documented yearly performance evaluation available upon request. Administrative staff confirmed that department directors are responsible for completing these evaluations, with assistance from the human resources department in tracking them, but were unable to locate the required documentation for CNA O. Additionally, the facility did not provide a policy regarding yearly performance reviews for staff. This deficiency was identified during a review of personnel records and staff interviews, with a facility census of 96 residents and a sample of 20 residents included in the review.
Failure to Ensure Safe Administration and Management of Enteral Nutrition
Penalty
Summary
Surveyors identified that the facility failed to ensure safe administration and management of enteral nutrition for four residents who were receiving tube feedings. Observations revealed that residents were repeatedly found lying flat or with insufficient elevation of the head of the bed while tube feedings were being administered, despite care plans and physician orders specifying that the head of the bed should be elevated to at least 30 or 45 degrees during and after feedings. This practice was not followed consistently, as evidenced by multiple instances where residents were observed in a flat or inadequately elevated position while their enteral feeding pumps were running. Additionally, the facility did not ensure that enteral feeding bags were properly labeled and dated. On several occasions, surveyors observed unlabeled and undated feeding bags containing unknown supplements being administered to residents. Staff interviews confirmed that the expectation was for all enteral feeding bags to be labeled with the date and time of administration to ensure consistent and safe nutrition delivery, but this was not consistently practiced. The facility also failed to provide a policy related to enteral nutrition when requested by surveyors. The residents involved had significant medical conditions, including severe cognitive impairment, dysphagia, quadriplegia, end-stage renal failure, and a history of aspiration or pressure ulcers. Despite these vulnerabilities and the presence of care plans and physician orders outlining specific protocols for enteral feeding, the facility did not adhere to these protocols, resulting in a deficiency related to the safe provision of enteral nutrition.
Failure to Provide Consistent Bathing and ADL Care to Dependent Residents
Penalty
Summary
The facility failed to provide consistent bathing and personal hygiene care to several dependent residents, as evidenced by gaps in documentation, resident interviews, and staff statements. One resident with multiple medical conditions, including a pressure ulcer, congestive heart failure, and functional limitations, was dependent on staff for all ADLs, including bathing. Documentation showed irregular intervals between baths, with some periods exceeding a week without evidence of bathing being offered or refused. The resident confirmed that sometimes more than a week would pass between baths, attributing this to staff shortages and her need for more assistance. Staff interviews corroborated that scheduled baths were sometimes missed due to staffing issues, and the care plan lacked clear direction on the resident's preferred bathing schedule. Another resident with diabetes, morbid obesity, and mental health diagnoses was also dependent on staff for all ADLs and was at risk for skin breakdown. Review of records over an 86-day period revealed only a few documented bathing opportunities, with many days marked as 'not applicable' and no evidence of refusals. The resident reported not having a bath in almost a month, and observations noted poor hygiene. Staff confirmed the resident often refused care, but there was no consistent documentation of offers or refusals, and the care plan directed staff to make multiple attempts and involve the nurse if care was refused. Additional residents, including one with hypertensive heart disease and another with spastic quadriplegic cerebral palsy, were also found to have inconsistent bathing care. Documentation for one resident showed no evidence of bathing or refusals over several months, despite a care plan specifying twice-weekly baths. Staff interviews indicated that a hospice aide provided some care, but facility staff were also responsible for offering baths. For the resident with cerebral palsy, records showed only a handful of baths over an 82-day period, with no evidence of refusals, and observations noted poor hygiene. In all cases, the facility's policy required consistent ADL care based on resident needs and preferences, but this was not consistently provided or documented.
Infection Control Lapses in Linen Handling, Equipment Storage, and Hand Hygiene
Penalty
Summary
Surveyors identified multiple infection control deficiencies during their review and observation of the facility. Uncovered linen carts and pillows were found in various locations, including a shower room and on top of linen carts, and bedspreads were stored inappropriately in a shower room marked with a 'Do Not Use' sign. Additionally, a resident's urinary catheter bag was observed dragging on the floor beneath a wheelchair during lunchtime, and another resident's CPAP machine was not stored in a sanitary manner. There were also issues with the storage of a nasal cannula and the positioning of a urine collection bag, which was not kept below the level of the bladder as required. Staff failed to consistently perform hand hygiene during critical care procedures. During wound care, administrative nurses and a licensed nurse entered a resident's room without performing hand hygiene, and one nurse failed to change gloves or sanitize hands between wound sites. Similar lapses were observed during catheter care and feeding tube dressing changes, where hand hygiene was not performed between glove changes. During medication administration via feeding tube, a nurse did not change gloves or perform hand hygiene after adjusting the resident's pillow, gown, and brief, and before administering water flushes and medication. These failures were in direct violation of the facility's infection prevention policy and placed residents at risk for infection.
Failure to Provide Trauma-Informed Social Services for Resident with PTSD
Penalty
Summary
The facility failed to identify and provide medically related social services to support a resident with a history of posttraumatic stress disorder (PTSD), cognitive communication deficit, anxiety, dementia, and depression. The resident's care plan lacked individualized, trigger-specific interventions to decrease exposure to triggers that could re-traumatize her. Staff interviews revealed that direct care staff were unaware of the resident's PTSD diagnosis and did not have access to information about potential triggers or effective interventions. The last trauma-informed care assessment for the resident was completed several years prior, and social services staff indicated that reassessment would only occur upon request from nursing administration. The care plan did not reflect current needs or strategies to address the resident's trauma history. Observations showed the resident with severely impaired cognition and no documented behaviors during assessment periods, despite frequent yelling out as reported by staff. The facility's policy required trauma-informed care and regular evaluation of interventions, but this was not implemented for the resident. Staff, including CNAs and nurses, expected to find information about the resident's PTSD and appropriate interventions in the care plan but did not. The lack of updated assessment and individualized care planning placed the resident at risk for further decline in emotional and mental well-being.
Failure to Ensure Proper Use and Monitoring of Low Air-Loss Mattresses for Pressure Ulcer Prevention
Penalty
Summary
Staff failed to ensure proper use and monitoring of low air-loss mattresses for two residents at risk for pressure ulcers. For one resident with severe cognitive impairment, end-stage renal failure, and a history of pressure ulcers, the low air-loss mattress was consistently set at the maximum weight setting of 400 lbs, despite the resident's actual weight being 228 lbs. The mattress pump had multiple preset weight options, but staff did not adjust the setting to match the resident's current weight as required by the manufacturer's instructions. Interviews with staff revealed inconsistent understanding of mattress settings, with some staff checking only if the pump was on and the bed inflated, rather than verifying the correct weight setting. Another resident, also with severe cognitive impairment, spastic quadriplegic cerebral palsy, and at risk for pressure ulcers, was found lying on a bed with a low air-loss mattress that was unplugged and not functioning. The resident's care plan indicated the use of a pressure-reducing mattress, but there was no documentation of monitoring the mattress's function. Staff interviews confirmed that checks were limited to ensuring the pump was on and the bed was inflated, without consistent verification of proper function or weight-based settings. The facility's policy required individualized interventions based on comprehensive assessment and risk, including the use of pressure redistribution surfaces. However, the failure to set the mattresses according to residents' weights and to ensure the equipment was plugged in and functioning represented a deviation from both manufacturer guidelines and facility policy. These actions and inactions placed the residents at risk for complications related to skin breakdown and pressure ulcers.
Failure to Provide Contracture Prevention and Restorative Care
Penalty
Summary
A resident with spastic quadriplegic cerebral palsy, severe cognitive impairment, and multiple comorbidities including muscle weakness and a history of pressure ulcers, was not provided with appropriate services and treatment to prevent worsening of contractures in his left hand. The resident's care plan specified the use of palm grips on both hands for four to six hours daily, monitoring of skin integrity, pain, and circulation, and a passive range of motion (ROM) program for the upper extremities. However, there was no documentation in the clinical record, Medication Administration Record (MAR), Treatment Administration Record (TAR), or other documentation systems that the restorative nursing program or application of palm grippers was provided during the review period. Multiple observations over several days showed the resident lying in bed with both hands tightly clenched and no contracture prevention devices in place. The resident's enteral feeding equipment was undated and unlabeled, and personal hygiene concerns were noted, including oily hair and body odor. The resident's call light was also observed to be out of reach. Interviews with nursing and therapy staff revealed uncertainty about responsibility for applying palm grippers and a lack of awareness regarding the resident's need for contracture prevention devices. The facility's own restorative nursing policy required proactive identification, care planning, and monitoring of restorative programs, with nursing assistants trained in restorative techniques. Despite this, the resident did not receive the prescribed interventions to maintain or improve range of motion, and there was no evidence of staff following the care plan or documenting the required restorative care.
Failure to Provide Timely Incontinence and Catheter Care
Penalty
Summary
Facility staff failed to provide timely incontinence care to a resident with dementia, metabolic encephalopathy, and other comorbidities, resulting in a bladder incontinence episode during a lunchtime meal in the dining room. This incident left a puddle of urine on the floor where other residents were eating. The resident was known to be frequently incontinent and required partial to moderate assistance with toileting, but staff did not anticipate or address the resident's needs prior to the meal, despite care plans and policies indicating the need for such interventions. Additionally, staff did not ensure proper management of an indwelling urinary catheter for another resident with severe cognitive impairment, obstructive uropathy, and a history of urinary tract infections. Observations showed that the resident's catheter collection bag was repeatedly placed above the level of the bladder, both in bed and while seated in a wheelchair, with urine pooling in the tubing. Staff interviews confirmed awareness of the requirement to keep the catheter bag below bladder level to prevent infection, but this was not consistently implemented or reinforced with the resident. Facility policies required staff to provide appropriate catheter care, maintain catheter bags below bladder level, and ensure timely toileting and incontinence care to prevent urinary tract infections and maintain resident dignity. However, these standards were not met, as evidenced by direct observations, staff interviews, and review of care plans and assessments.
Failure to Provide Adequate Equipment and Accommodations for Resident Needs
Penalty
Summary
The facility failed to ensure adequate bariatric equipment was available to meet the needs and preferences of a resident with morbid obesity. The resident, who weighed over 700 pounds and was dependent on staff for most activities of daily living, did not have access to a mechanical lift or wheelchair that could accommodate his weight. As a result, staff were unable to obtain required monthly weights, and there was no evidence of bathing or transfers occurring for several months, with no documentation of refusals. When movement was necessary, such as during an emergency, staff had to call Emergency Medical Response to move the resident using a gurney, as the facility lacked appropriate equipment. The facility also did not provide a policy regarding accommodation of needs for such residents. Another deficiency involved a resident with severe cognitive impairment who required a wheelchair for mobility. Observations revealed that the resident's call light was repeatedly clipped to the wall and not within reach, and the resident was transported in the wheelchair without foot pedals in place. Staff interviews confirmed that call lights should be within reach and foot pedals should be used when pushing residents in wheelchairs, but these practices were not followed. The facility did not provide policies related to the use of foot pedals or call lights. These failures resulted in unmet care needs for both residents, including the inability to obtain weights, lack of appropriate bathing and transfer support, and increased vulnerability due to lack of access to call lights and proper wheelchair equipment. The report documents that these practices placed the residents at risk for impaired quality of life and health complications related to unmet needs.
Failure to Develop Individualized, Person-Centered Care Plans for Two Residents
Penalty
Summary
The facility failed to develop and implement comprehensive, individualized care plans for two residents, resulting in unmet care needs. For one resident with diagnoses including PTSD, cognitive communication deficit, anxiety, dementia, and depression, the care plan did not include person-centered interventions specific to her trauma-based care. The care plan lacked details on triggers, de-escalation strategies, and ways to prevent re-traumatization, despite documentation of her severe cognitive impairment and risk factors such as self-care deficits, falls, and decreased socialization. Staff interviews revealed a lack of awareness regarding the resident's PTSD diagnosis and absence of trauma-informed interventions in the care plan. Another resident with chronic kidney disease, quadriplegia, diabetes, dysphagia, and pressure ulcers was also found to have an incomplete care plan. The plan did not address person-centered activities, despite the resident's severe cognitive impairment and total dependence on staff for daily care. There was no documentation of activity participation, and staff confirmed that the resident enjoyed music and television, which were not reflected in the care plan or provided during observations. The facility's policy required timely, person-centered, and interdisciplinary care planning, but these requirements were not met for the two residents. The lack of individualized interventions and activity planning placed the residents at risk for impaired care and unaddressed psychosocial needs, as evidenced by staff interviews and review of medical records.
Failure to Revise Care Plans for Visitation and Fall Prevention
Penalty
Summary
The facility failed to update and revise the care plans for two residents to reflect their current care needs and safety requirements. For one resident with a history of aphasia, hemiparesis, cerebral infarction, muscle weakness, and depression, the care plan did not include updated visitation requirements following an incident where her family representative was observed acting aggressively towards her. Although the resident expressed a desire for supervised or restricted visitation, and staff and administrative nurses acknowledged that this information should be reflected in the care plan, the necessary updates were not made. The facility's own policy required that care plans be reviewed and revised by an interdisciplinary team with input from the resident and their representative, but this was not followed in this case. Another resident, who had diagnoses including lack of coordination, right hip fracture, dementia, muscle weakness, aphasia, and communication deficits, experienced multiple falls, including one resulting in a right hip fracture. Despite repeated falls and changes in her condition, the care plan was not revised to include new long-term interventions to prevent future falls. Staff interviews confirmed that while some fall interventions were in place, such as keeping the bed in the lowest position and using a floor mat, there were no new interventions added after the most recent incidents. The care plan lacked comprehensive updates to address the resident's ongoing high risk for falls, as required by facility policy. These deficiencies were identified through observations, interviews, and record reviews, and were found to place the residents at risk for impaired care due to uncommunicated or inadequately addressed care needs. The facility's failure to revise and update care plans in a timely and comprehensive manner was contrary to its own policies and placed the affected residents at risk for compromised safety and quality of life.
Failure to Provide Appropriate Call Light Device for Dependent Resident
Penalty
Summary
A deficiency was identified when a resident with spastic quadriplegic cerebral palsy, severe cognitive impairment, and significant limitations in range of motion was not provided with an appropriate call light device. The resident's care plan specified the need for a mechanical pad call light to request staff assistance, but observations revealed that only a push button call light was available, which was out of the resident's reach and not operable by the resident due to clenched hands and lack of palm grippers. Staff interviews confirmed that the resident could not use the push button call light, and there was uncertainty among staff regarding who was responsible for assessing residents for appropriate equipment. The resident was dependent on staff for activities of daily living, had a feeding tube, and was at risk for pressure ulcers, as documented in the medical record and care assessments. Despite these needs and the facility's policy to provide appropriate treatment and services to maintain or improve ADL abilities, the required touch pad call light was not provided. This failure resulted in the resident being unable to communicate needs or call for assistance as intended in the care plan.
Failure to Ensure Proper Use and Storage of Respiratory Equipment
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for two residents by not ensuring that physician-ordered respiratory equipment was used and stored as directed. One resident with diagnoses including respiratory failure, COPD, CHF, and dementia was ordered to receive oxygen therapy at three liters per minute via nasal cannula (NC). Despite this, observations showed that the resident frequently did not have the NC in place, with the oxygen concentrator running but the NC left unbagged on the bedside table or bed. Staff interviews confirmed that the resident was often non-compliant with wearing the NC and did not consistently store it in the provided bag when not in use, despite reminders and the presence of a care plan and facility policy requiring proper storage and continuous use of oxygen as ordered. Another resident, who had diagnoses such as hypertensive heart disease, heart failure, diabetes, respiratory failure, obesity, and was on hospice care, was ordered to use a CPAP device while sleeping or napping, with specific instructions for cleaning and storage. Observations revealed that the CPAP mask was left in the windowsill and not stored in a sanitary manner as required. Staff confirmed that the resident was unable to properly store the mask and that all respiratory equipment should be placed in a labeled bag when not in use, in accordance with facility expectations. The facility's own policy on oxygen administration and storage required that respiratory equipment be stored in a bag labeled with the resident's name when not in use. However, both residents' respiratory equipment was found not to be stored appropriately, and in one case, the resident was not receiving oxygen therapy as ordered. These failures were confirmed through direct observation, record review, and staff interviews.
Failure to Identify and Address Trauma Triggers for Resident with PTSD
Penalty
Summary
The facility failed to identify and address trauma-based triggers for a resident diagnosed with post-traumatic stress disorder (PTSD), as well as other conditions including cognitive communication deficit, anxiety, dementia, and depression. The resident's care plan did not include individualized, trigger-specific interventions to prevent re-traumatization, despite documentation of PTSD in the medical record and care assessments. Staff interviews revealed a lack of awareness regarding the resident's PTSD diagnosis and the absence of specific interventions or information about potential triggers in the care plan. The trauma-informed care assessment for the resident had not been updated since admission, and reassessment was only performed upon request, rather than routinely. Observations showed the resident with severely impaired cognition and no documented behaviors during assessment periods. Staff, including CNAs, nurses, and social services, indicated they expected to find information about trauma triggers and interventions in the care plan but confirmed this information was missing. The facility's policy required trauma-informed, culturally competent care, including identification and mitigation of triggers, but this was not implemented for the resident in question.
Failure to Assess and Inform on Bed Rail Risks with Low Air-Loss Mattresses
Penalty
Summary
The facility failed to ensure that two residents, both using low air-loss mattresses, received appropriate safety assessments for the use of bed rails that specifically acknowledged the risks associated with these mattresses. For one resident with multiple medical diagnoses including diabetes, morbid obesity, and schizoaffective disorder, documentation showed dependency on staff for all activities of daily living and a care plan that included bed rails to aid in mobility. However, the assessment did not address the risks posed by the combination of bed rails and a low air-loss mattress, and there was no documentation that the resident or their representative was informed of these specific risks or provided informed consent. For the second resident, who had spastic quadriplegic cerebral palsy, severe cognitive impairment, and was dependent on staff for all ADLs, the care plan also included the use of bed rails. The assessment again lacked consideration of the risks associated with the low air-loss mattress. Observations revealed that the resident was unable to use the bed rails for mobility or transfers, and the low air-loss mattress was found unplugged and not functioning. Staff interviews indicated uncertainty about whether bed rail assessments included evaluation of low air-loss mattresses, and there was no evidence that the risks and benefits were reviewed with the resident's representative as required by facility policy. The facility's policy required that all risks and benefits be reviewed prior to bed rail installation and that ongoing inspections and assessments be conducted. Despite this, both residents' records lacked documentation of risk assessments specific to the use of bed rails with low air-loss mattresses, as well as evidence of informed consent and education regarding potential risks. These omissions resulted in the residents being placed at risk for uninformed decisions and impaired safety related to bed rail use.
Failure to Maintain and Retain Daily Nurse Staffing Data
Penalty
Summary
The facility failed to maintain and retain the required daily nurse staffing data for the mandated 18-month period. Record review revealed that posted staffing documentation was missing for 29 specific dates, and on 12 additional dates, the resident census was not recorded. Furthermore, eight dates lacked documentation of the total number of nursing hours. Interviews with administrative staff indicated that responsibility for posting and storing the staffing sheets was shared between the administrative nurse, front desk staff, and medical records staff. The facility's own staffing policy required daily posting and retention of staffing data, in accordance with federal regulations.
Resident Fall Due to Inadequate Supervision
Penalty
Summary
The facility failed to ensure an environment free from preventable accidents for a resident, identified as R1, who experienced a fall resulting in a scalp laceration requiring 13 staples. On the day of the incident, a Certified Nurse Aide (CNA) was providing incontinence care for R1 and noticed that the resident was close to the edge of the bed. While attempting to clean the resident, the CNA moved her hand to wipe R1's buttocks, causing R1 to roll off the bed onto the floor. This incident led to R1 being sent to the Emergency Department for evaluation and treatment. R1's medical history included diagnoses of cerebral infarction, quadriplegia, lack of coordination, and generalized muscle weakness. The resident had severe cognitive impairments and was dependent on staff for activities of daily living. R1's care plan indicated that he was totally dependent on one to two staff members for repositioning and turning in bed, and one staff member for incontinence care. However, during the incident, the CNA was informed by another CNA that R1 required only one-person assistance, which contributed to the fall. The facility's investigation revealed that the CNA did not follow the care plan's directive for bed mobility and incontinence care, which required adequate supervision and assistance. The facility's policies on fall management and activities of daily living emphasized the need for appropriate safety measures and supervision to prevent accidents. The failure to adhere to these policies and the care plan resulted in the resident's fall and subsequent injury.
Failure to Ensure Safe Transfer with Mechanical Lift
Penalty
Summary
The facility failed to ensure a resident remained free from accident hazards when a Certified Nurse Aide (CNA) used a mechanical lift by himself to transfer the resident. The resident, who had multiple diagnoses including osteomyelitis, multiple sclerosis, and paraplegia, required substantial to total assistance for all activities of daily living and mobility. The care plan specifically indicated that the resident required the use of a mechanical lift with two staff members for transfers. However, on the day of the incident, the CNA attempted to transfer the resident alone, resulting in the resident falling from the lift and fracturing her pelvis. The incident occurred when the CNA lifted the resident from her electric wheelchair using the mechanical lift, and the resident began to slide from the sling. The CNA attempted to lower the resident to the floor, but she hit her head on the bed frame and then the floor. The resident reported pain in her neck and the back of her head. Subsequent X-rays revealed a non-operable left pubic rami fracture. Witness statements from other CNAs and Licensed Nurses confirmed that the CNA had attempted the transfer alone, contrary to the facility's policy requiring two staff members for such transfers. The facility's policy for the safe use of mechanical lifts, revised in August of the previous year, mandated that two staff members be present during transfers. Despite this policy, the CNA proceeded with the transfer alone, leading to the resident's fall and injury. The facility's failure to adhere to its own safety protocols placed the resident in immediate jeopardy and at risk for significant 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.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
