Below average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Medicalodges Arkansas City during CMS and state inspections, most recent first.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
Surveyors identified multiple unsanitary conditions in the kitchen and kitchenette, including dirty equipment, food debris on surfaces and carts, improperly labeled and uncovered food items, and inadequate cleaning of storage areas and utensils. These failures to maintain sanitary food preparation and storage practices were confirmed by dietary staff and were not in accordance with facility policies.
Staff failed to follow proper infection control practices in laundry services, including transporting clean clothes uncovered, storing soiled laundry in open containers, and placing non-laundry items on clean folding counters. Staff interviews confirmed these practices were inappropriate, and the facility lacked a specific policy for clean laundry storage and delivery.
Surveyors found that two resident halls and a supply storage room were not maintained in a clean and homelike condition, with issues such as dust, debris, dead bugs, rusted carts and fixtures, discolored and damaged toilet seats, missing caulk, and boxes of medical supplies stored directly on the floor. These deficiencies were confirmed by housekeeping and maintenance staff and were not in accordance with facility policy.
The facility did not complete an annual performance review for one CNA who had been employed for over a year, as required by facility policy. Review of personnel files and staff interviews confirmed the absence of a documented evaluation.
The facility did not timely report suspected abuse, neglect, or theft, nor did it report the results of the investigation to the proper authorities as required. Documentation review showed that mandated notifications and reporting were not completed within the required timeframe.
A resident with schizophrenia, anxiety, and delusional disorders was prescribed and received an antidepressant, but the Quarterly MDS inaccurately documented that no antidepressant was given during the assessment period. This error was confirmed by an administrative nurse, and the facility did not provide a policy for MDS completion.
A resident with severe cognitive impairment and a history of psychotic disorder with delusions and high-risk behaviors received antipsychotic and antidepressant medications, but the care plan did not include staff instructions regarding Black Box Warnings (BBW) for these medications, contrary to facility policy.
A resident with severe cognitive impairment and ongoing weight loss did not have their care plan updated to include physician-ordered fortified diet and nutritional supplements. Staff did not consistently provide required built-up utensils or offer drinks during meals, and interviews confirmed the care plan was not revised to reflect current interventions, resulting in uncommunicated care needs.
The facility did not ensure the use of wheelchair foot pedals during staff-assisted transport for two residents with mobility and cognitive impairments, resulting in unsafe conditions. Additionally, after a fall, a resident with severe cognitive impairment received only reminders to use the call light, despite staff acknowledging this was not an effective intervention for someone with low cognition. The facility lacked a policy on foot pedal use and did not consistently update care plans with appropriate interventions after falls.
A resident with chronic kidney disease and urinary incontinence, who required substantial assistance, did not receive consistent incontinence care or timely monitoring and reporting of UTI symptoms. Despite ongoing antibiotic therapy, the resident continued to report symptoms, experienced increased confusion, and was left in a wheelchair overnight without prompt intervention. Facility staff did not consistently follow care plan interventions or facility policies, resulting in the resident being sent to the hospital for further evaluation.
A resident with severe cognitive impairment and a history of significant weight loss did not receive the ordered fortified diet or consistent nutritional interventions, despite recommendations from the RD and physician orders. Staff failed to provide fortified foods, did not use required adaptive utensils, and did not consistently offer nutritional supplements, resulting in continued weight loss and unmet care plan directives.
A resident with severe cognitive impairment and multiple mental health diagnoses exhibited ongoing inappropriate behaviors, including wandering, intruding on others' privacy, and inappropriate touching. Despite being on 1:1 monitoring, staff did not consistently intervene or redirect the resident as required, and the facility lacked a behavioral management policy. This failure placed the resident at risk for mental anguish and impaired quality of life.
Surveyors found that the facility did not ensure a safe and clean environment in the laundry area, with large pieces of paint peeling above dryers and multiple broken, hanging fluorescent light covers above clean laundry areas. Staff interviews confirmed these issues were known, and facility policy requires maintenance of a clean and hazard-free environment.
A male resident with severe cognitive impairment and a history of high-risk sexual behavior repeatedly engaged in sexually inappropriate acts toward cognitively impaired female residents, including unwanted touching and public masturbation. Despite staff observing and documenting these incidents, the facility failed to notify the LNHA, SA, or LE as required, and investigation reports were incomplete or missing. This deficiency in abuse prevention and reporting practices placed vulnerable residents at risk.
A male resident with severe cognitive impairment and a history of high-risk sexual behavior repeatedly engaged in inappropriate sexual contact with cognitively impaired female residents, including touching and masturbating in public areas. Staff often redirected the resident but failed to consistently implement new interventions or conduct thorough investigations, and law enforcement was not notified as required. Investigation reports were incomplete or missing, and staff interviews revealed inconsistent understanding of abuse prevention protocols, resulting in immediate jeopardy for vulnerable residents.
A cognitively impaired resident with a history of high-risk sexual behavior repeatedly engaged in unwanted sexual contact with other cognitively impaired residents who could not consent. Despite multiple incidents, staff responses were limited to redirection or returning the resident to his room, and the facility did not consistently implement or update interventions to prevent further abuse. Investigation reports were incomplete, law enforcement was not notified as required, and care plans were not always updated, leaving vulnerable residents at risk.
A resident with a history of muscle weakness and hemiplegia was injured in a fall when a CNA failed to use a gait belt during a transfer in the shower room. The resident, who required assistance for transfers, was lowered to the floor by the CNA, resulting in a twisted ankle and fracture. The facility's investigation confirmed the CNA did not follow the standard practice of using a gait belt, contributing to the incident.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report documents that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Unsanitary Food Preparation and Storage Conditions Identified
Penalty
Summary
Surveyors observed multiple failures in the facility's kitchen and kitchenette regarding the preparation and serving of food under sanitary conditions. During an initial tour, they found a stationary can opener covered in a sticky, thick substance, two machines used for pureeing food with dried food and liquids, and a microwave oven with dried food and liquids both inside and outside. Four cutting boards had deep grooves, making them unsanitizable, and cabinet doors and handles throughout the kitchen had dried food, liquids, and a sticky buildup. Inside the cabinets, kitchen supplies rested on surfaces with a sticky, unknown substance. A three-tiered metal cart holding clean dishes and utensils had food debris on all layers, and eight plastic containers for utensils had sticky substances on the lids. Carts used to transport fluids to residents also had food debris, and containers of dry cereal had dusty lids. In the reach-in freezer, a five-gallon container of sherbet ice cream was uncovered and undated, an empty gallon container of vanilla ice cream was undated, and the freezer doors had dried food and liquid. Additionally, one freezer had three boxes of food with heavy ice buildup. In the kitchenette, the hand-washing sink was visibly dirty with a brown substance and trash, and the microwave had dried food and liquid inside and out. The trash can was covered in dried food and liquid, and the freezer contained three open containers of ice cream that were unlabeled and undated, with food debris and hair on the bottom shelf. The two-door cabinet also had dried food and liquids. Dietary staff confirmed these concerns. Facility policies required proper labeling of foods stored for more than 24 hours and regular cleaning of kitchen equipment and surfaces, but these were not followed as observed during the survey.
Inadequate Infection Control in Laundry Services
Penalty
Summary
Facility staff failed to implement adequate infection control practices in the laundry services area. Observations revealed that clean resident clothes were transported uncovered down hallways and placed in resident rooms, contrary to infection control protocols. Soiled laundry was found stored in open containers and left exposed on transport bins. The soiled laundry storage area also contained a housekeeping cart and dirty mop buckets placed on drainage grates behind washers, indicating improper separation of clean and soiled items. Additionally, the clean laundry folding counter was cluttered with non-laundry items such as a dryer sheet box, a dumbbell, a stuffed dog, large totes, a binder, a laptop, speakers, and a refrigerator used for staff personal food. Staff interviews confirmed that only clean laundry should be on the folding counter and that soiled items and cleaning equipment should not be stored in laundry areas. It was also noted that the facility lacked a policy specifically addressing clean laundry storage and delivery, despite having a general infection management process policy.
Failure to Maintain Clean and Homelike Environment in Resident Halls and Shower Rooms
Penalty
Summary
Surveyors observed that the facility failed to maintain a clean, comfortable, and homelike environment in two of the three resident halls, specifically in the shower rooms on Hall A and Hall B, as well as a supply storage room on Hall A. In Hall A, the shower room window had accumulated dust, debris, and dead bugs, and a four-tiered metal cart used for clean linens and toiletries showed multiple areas of rust. The toilet seat in the same room was discolored and had several gouged areas. The storage room contained two boxes, one with urinary catheter supplies and another with wound care items, both resting directly on the floor. In Hall B, similar issues were noted, including a shower room window with dust, debris, and dead bugs, a rusted metal cart for clean linens, missing caulk in the shower corner, rust around the hand-washing sink faucet and drain, and a rusted paper towel dispenser. These conditions were confirmed by housekeeping and maintenance staff during the environmental tour. The facility's policy requires that sinks and paper towel dispensers be kept clean and that boxes be stored off the floor at all times.
Failure to Complete Annual Performance Review for CNA
Penalty
Summary
The facility failed to complete an annual performance review for one of five Certified Nurse Aides (CNA) reviewed, specifically for CNA M, who had been employed for over one year. A review of personnel files showed that CNA M, hired on 12/13/23, did not have a documented annual performance evaluation in her file. During an interview, administrative staff confirmed that the annual evaluation for CNA M had not been completed. Facility policy requires that all full and part-time employees receive a formal, written evaluation on an annual basis.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on a review of facility practices and documentation, which showed that when an incident of suspected abuse, neglect, or theft occurred, the required notifications and reporting to authorities were not completed within the mandated timeframe. The report does not provide specific details about the individuals involved or the nature of the incident, but it clearly states that the reporting and communication requirements were not met.
Inaccurate MDS Assessment for Antidepressant Use
Penalty
Summary
The facility failed to complete an accurate Minimum Data Set (MDS) assessment for a resident with diagnoses of schizophrenia, anxiety, and delusional disorders. The resident's electronic medical record showed an active physician's order for Paxil, an antidepressant, prescribed for anxiety. During the assessment period for the Quarterly MDS, the resident received this antidepressant medication. However, the MDS inaccurately documented that the resident did not receive antidepressant medications during the observation period. This inaccuracy was confirmed by an administrative nurse, who acknowledged that the Quarterly MDS did not reflect the resident's actual medication administration. The facility reported using the Resident Assessment Instrument (RAI) for MDS completion but did not provide a policy regarding this process. The inaccurate documentation could result in unidentified care needs for the resident.
Failure to Address Black Box Warnings in Care Plan for Resident Receiving Psychotropic Medications
Penalty
Summary
A deficiency occurred when the facility failed to complete a comprehensive care plan addressing Black Box Warnings (BBW) for a resident with significant mental health needs. The resident had a diagnosis of psychotic disorder with delusions and high-risk behaviors, and was assessed as having severe cognitive impairment. Despite receiving antipsychotic and antidepressant medications, including Zyprexa and Sertraline, the care plan did not include staff instructions regarding BBW for these medications. The facility's policy required that medications be addressed in each resident's care plan, but this was not done for this resident. The issue was identified through a review of the resident's electronic medical record, Minimum Data Set (MDS) assessments, and care plan documentation. The resident's Medication Administration Record (MAR) confirmed that the medications were administered as ordered. An administrative nurse confirmed the expectation that all BBW medications should be included in the care plan, but this was not reflected in the resident's documentation.
Failure to Update Care Plan for Resident with Weight Loss
Penalty
Summary
The facility failed to revise the care plan for a resident with severely impaired cognition who experienced significant weight loss. Despite documented orders for a fortified diet and nutritional supplements, the resident's care plan did not reflect these interventions. The resident's medical record showed ongoing weight loss, with the registered dietician recommending a fortified diet and physician notification due to inadequate oral intake. However, the care plan was not updated to include the fortified diet or health shakes, and staff were not consistently providing the required built-up utensils during meals as directed in the care plan. Observations revealed that staff did not offer the resident drinks during meals and failed to provide built-up utensils, which were necessary for the resident's ability to eat independently. Interviews with staff confirmed that the care plan had not been updated to include the fortified diet and that there was uncertainty about the use of built-up utensils. The facility's policy required the care plan to be an active, person-centered document reflecting current care needs, but this was not followed, resulting in uncommunicated care needs and placing the resident at risk for continued weight loss.
Failure to Prevent Accident Hazards and Implement Appropriate Fall Interventions
Penalty
Summary
The facility failed to ensure that areas were free from accident hazards and that adequate supervision and interventions were provided to prevent accidents for multiple residents. For one resident with a history of stroke and left-sided weakness, staff propelled his wheelchair without ensuring his foot was on the foot pedal, resulting in his foot becoming caught under the wheelchair and causing pain. Staff acknowledged that the resident's foot did not always stay on the pedal, and it was the facility's expectation that foot pedals be used during transport, but there was no policy in place to guide this practice. Another resident with severe cognitive impairment and lower extremity weakness was transported in a wheelchair without foot pedals, causing his feet to skim the floor. Staff stated that the wheelchair lacked foot pedals because the resident sometimes propelled himself, but also confirmed that foot pedals should be used when staff are propelling residents. Again, there was no facility policy provided regarding the use of foot pedals during wheelchair transport. Additionally, the facility failed to implement appropriate interventions following a fall for a resident with intellectual disability and severe cognitive impairment. After a non-injury fall, the care plan was updated to include reminders for the resident to use the call light, despite staff and administrative acknowledgment that such reminders were not appropriate for residents with low cognitive function. The facility's falls management policy required care plans to be reviewed and revised with each fall and for new interventions to be implemented, but this was not consistently done.
Failure to Provide Adequate Incontinence and UTI Prevention Care
Penalty
Summary
The facility failed to provide adequate care and services to prevent urinary tract infections (UTIs) for a resident with a history of recurrent UTIs, chronic kidney disease, and urinary incontinence. The resident was always incontinent of urine, required substantial to maximum assistance for toileting hygiene, and was dependent on staff for activities of daily living. The care plan included interventions such as monitoring for signs and symptoms of infection, encouraging fluids, and providing proper perineal care with each incontinence episode. However, documentation and interviews revealed lapses in monitoring, reporting, and timely response to changes in the resident's condition. Despite ongoing antibiotic therapy for a recent UTI, the resident continued to report symptoms such as burning and stinging upon urination and expressed concerns that the infection was still present. Staff interviews indicated that standard practice included toileting every two hours, encouraging fluids, and monitoring for behavioral or urinary changes. However, there were instances where changes in the resident's mental status, increased confusion, and reports of burning upon urination were not promptly communicated or acted upon. The resident was left in her wheelchair all night, and staff failed to notify the nurse of changes in her condition in a timely manner. Progress notes and late entries documented that the resident experienced increased confusion, unusual behavior, and eventually became unresponsive with emesis, leading to her transfer to the hospital for further evaluation. The facility's policies required regular assessment, monitoring, and individualized care planning for incontinence management, but these were not consistently implemented. The lack of timely identification and reporting of UTI symptoms and inadequate incontinence care placed the resident at risk for ongoing infection and related complications.
Failure to Implement Fortified Diet and Nutritional Interventions for Resident with Significant Weight Loss
Penalty
Summary
A deficiency occurred when the facility failed to implement and provide necessary nutritional interventions for a resident with a history of significant weight loss and severely impaired cognition. The resident had diagnoses including unspecified psychosis, depression, and anxiety, and was identified as being at risk for weight instability, impaired fluid balance, abnormal lab values, and impaired skin integrity. Despite a physician's order for a fortified foods diet and recommendations from the registered dietician to add fortified foods due to ongoing weight loss, the resident's care plan did not reflect these interventions, and staff did not consistently provide fortified foods or health shakes as ordered. Observations revealed that staff did not offer drinks to the resident during meals and did not use built-up utensils as specified in the care plan. Staff interviews confirmed that the resident was dependent on staff for meal assistance, often refused supplements, and did not receive fortified foods at meals. Dietary staff were unaware of the fortified diet order, and the resident's meal did not include any fortified items. Documentation showed that the resident continued to lose weight, with a significant 10% loss over several months, and frequently refused the prescribed nutritional supplements. The facility's policy required individualized interventions and care plan updates in response to significant weight loss, but these were not implemented for the resident. Communication lapses between nursing and dietary staff resulted in the failure to provide the ordered fortified diet, and staff did not consistently follow the care plan interventions designed to address the resident's nutritional needs.
Failure to Implement Effective Behavioral Interventions for Resident with Severe Cognitive Impairment
Penalty
Summary
The facility failed to implement effective behavioral interventions for a resident with multiple mental health diagnoses, including anxiety disorder, severe intellectual disabilities, unspecified mood disorder, insomnia, and impulsiveness. The resident exhibited behaviors such as wandering, intruding on others' privacy, and inappropriate touching, as documented in the electronic health record and care plans. Despite being placed on 1:1 monitoring due to these behaviors, the interventions outlined in the care plan, such as immediate redirection and staff assistance in developing appropriate coping methods, were not consistently followed. Multiple progress and behavior notes indicated ongoing incidents where the resident was not easily redirected, ignored staff attempts to assist, and continued to display inappropriate behaviors, including loud outbursts, foul language, and attempts to touch staff and other residents. Specific incidents included the resident touching a female resident inappropriately, grabbing and hugging a female surveyor without staff intervention, and repeatedly grabbing a CNA's arm without being redirected. Staff interviews confirmed that the 1:1 monitoring was implemented due to the resident's inappropriate behaviors, but staff did not always intervene or redirect the resident as required. Additionally, the facility was unable to provide a policy for behavioral management when requested. The lack of consistent staff intervention and absence of a behavioral management policy contributed to the facility's failure to provide necessary behavioral health care and services, placing the resident at risk for mental anguish, social isolation, and impaired quality of life.
Failure to Maintain Safe and Clean Laundry Area
Penalty
Summary
Surveyors observed that the facility failed to maintain a safe and clean environment in the laundry area. Specifically, large pieces of paint were found peeling off around and above the dryers in the dryer-maintenance access room. Additionally, multiple fluorescent light fixture covers were broken and hanging, with one cover located above the clean laundry hanging counter and another above the clean laundry delivery carts. Paint was also observed flaking off the ceiling above the clean laundry delivery carts. These conditions were directly observed by surveyors during their inspection. Interviews with facility staff confirmed awareness of these issues. Maintenance staff indicated that the flaking paint was not considered a significant problem due to the enclosure of dryer elements and electrical components. However, administrative and housekeeping staff acknowledged that peeling paint and broken light covers, especially above clean linen and laundry areas, were unacceptable. Facility policy requires that all areas be maintained in a clean, orderly, and safe manner, free from hazards such as peeling paint and broken fixtures.
Failure to Report and Investigate Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to report multiple incidents of resident-to-resident abuse involving a male resident with severe cognitive impairment and a history of high-risk sexual behavior. This resident repeatedly engaged in sexually inappropriate behaviors, including touching and grabbing the breasts and legs of cognitively impaired female residents, masturbating in the presence of others, and making sexually explicit comments. Despite these incidents being observed and documented by staff, the facility did not notify the Licensed Nursing Home Administrator (LNHA), State Agency (SA), or Law Enforcement (LE) as required by policy and regulation. The male resident's electronic health record documented diagnoses of altered mental status, psychotic disorder, high-risk sexual behavior, and Alzheimer's disease, with a severely impaired cognition score. The care plan identified risks for sexually inappropriate behaviors and included interventions such as one-on-one monitoring and medication for sexual aggression. However, after the resident returned from an acute behavioral facility, the only intervention implemented was medication, and no additional measures were taken to prevent further abuse. Staff continued to observe and document incidents of inappropriate sexual contact and behavior, but these were not consistently investigated or reported to the appropriate authorities. Interviews with staff and administrative personnel revealed a lack of consistent understanding and execution of reporting requirements. Some staff believed that law enforcement should only be notified if harm occurred or if requested by a resident's family, while others acknowledged that any unwanted sexual contact should be reported. Investigation reports for several incidents were incomplete or missing, and there was no documentation that law enforcement was notified for any of the incidents. This failure to report and investigate placed cognitively impaired female residents at risk and constituted a deficiency in the facility's abuse prevention and reporting practices.
Removal Plan
- The facility placed R1 on one-on-one monitoring until an appropriate alternate placement was secured.
- The facility notified Law Enforcement.
- LN I received disciplinary action for failure to report the incident.
- LN F received disciplinary action for failure to report the incident.
- The facility updated R2 and R3's Care Plans to include social services follow-up with each resident weekly and as needed for their psychosocial well-being.
- The facility updated R1's Care Plan to include one-on-one monitoring until appropriate alternate placement was secured. Staff would assist R1 to a private location when fondling his genitals.
- The facility immediately educated all staff regarding abuse prevention, reporting, and expectations related to immediate interventions and investigations.
- The facility re-educated all staff on the definition of one-on-one monitoring with associated documentation.
- The facility held an Ad-hoc Quality Assurance Process Improvement (QAPI) meeting by telephone.
Failure to Protect Residents from Repeated Sexual Abuse and Inadequate Investigation
Penalty
Summary
The facility failed to immediately implement protective measures and conduct thorough investigations following multiple incidents of resident-to-resident abuse involving a male resident with severe cognitive impairment and a history of high-risk sexual behavior. This resident repeatedly engaged in inappropriate sexual behaviors, including touching the breasts and legs of cognitively impaired female residents and masturbating in the presence of others. Despite these incidents, the facility did not consistently initiate or update interventions to prevent further abuse, nor did it always investigate or document the incidents as required. Key events included the male resident grabbing the breast of a female resident, rubbing the leg of another unidentified female resident, and attempting to touch another female resident's leg. In several cases, staff redirected the resident or moved the affected resident but did not implement new interventions or conduct investigations. The facility also failed to notify law enforcement after incidents of unwanted sexual contact, despite policy requirements and the inability of the affected residents to provide consent. Investigation reports were often incomplete or missing, lacking documentation of law enforcement notification and witness statements. Interviews with staff and administrative personnel revealed inconsistent understanding and application of abuse prevention protocols. Some staff were unaware of specific incidents or did not recognize the need for investigation and reporting. Administrative staff confirmed that law enforcement was not notified for any of the incidents and that some events were not fully investigated because they were not believed to be sexual in nature. The facility's actions and inactions placed cognitively impaired female residents at risk and resulted in a finding of immediate jeopardy.
Removal Plan
- The facility placed R1 on one-on-one monitoring until an appropriate alternate placement was secured.
- The facility notified Law Enforcement.
- LN I received disciplinary action for failure to report the incident.
- LN F received disciplinary action for failure to report the incident.
- The facility updated R2 and R3's Care Plans to include social services follow-up with each resident weekly and as needed for their psychosocial well-being.
- The facility updated R1's Care Plan to include one-on-one monitoring until appropriate alternate placement was secured. Staff would assist R1 to a private location when fondling his genitals.
- The facility immediately educated all staff regarding abuse prevention, reporting, and expectations related to immediate interventions and investigations.
- The facility re-educated all staff on the definition of one-on-one monitoring with associated documentation.
- The facility held an Ad-hoc Quality Assurance Process Improvement (QAPI) meeting by telephone.
Failure to Prevent and Respond to Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to protect residents from resident-to-resident sexual abuse, specifically involving a cognitively impaired resident with a history of high-risk sexual behavior and Alzheimer's disease. This resident repeatedly engaged in unwanted sexual advances and physical contact with other cognitively impaired residents who were unable to consent. Despite multiple incidents of inappropriate touching, including grabbing and rubbing other residents, the facility did not consistently implement or update interventions to prevent further abuse. Staff responses were limited to redirecting the resident or returning him to his room, without establishing effective ongoing measures to ensure the safety of other residents. The resident's care plan documented cognitive loss, severe memory impairment, and a risk for sexually inappropriate behaviors. Although the care plan included some interventions such as one-on-one monitoring and psychiatric evaluation, these were not consistently or effectively applied following each incident. Several incidents were not fully investigated, and there was a lack of documentation regarding notification of law enforcement or comprehensive follow-up. The facility also failed to maintain thorough investigation reports and did not always update care plans or implement new interventions after each event. Interviews with staff and administrative personnel revealed inconsistent understanding and application of abuse prevention protocols. Some staff were unaware of specific incidents, and there was confusion about when to notify law enforcement. The facility's own policy required immediate action and reporting of abuse, but this was not followed in multiple instances. As a result, cognitively impaired residents, particularly those unable to consent, were left vulnerable to repeated sexual abuse, placing them in immediate jeopardy.
Removal Plan
- The facility placed R1 on one-on-one monitoring until an appropriate alternate placement was secured.
- The facility notified Law Enforcement.
- LN I received disciplinary action for failure to report the incident.
- LN F received disciplinary action for failure to report the incident.
- The facility updated R2 and R3's Care Plans to include social services follow-up with each resident weekly and as needed for their psychosocial well-being.
- The facility updated R1's Care Plan to include one-on-one monitoring until appropriate alternate placement was secured. Staff would assist R1 to a private location when fondling his genitals.
- The facility immediately educated all staff regarding abuse prevention, reporting, and expectations related to immediate interventions and investigations.
- The facility re-educated all staff on the definition of one-on-one monitoring with associated documentation.
- The facility held an Ad-hoc Quality Assurance Process Improvement (QAPI) meeting by telephone.
Failure to Use Gait Belt Results in Resident Injury
Penalty
Summary
The facility failed to ensure the use of a gait belt while assisting a resident, identified as R1, in the shower room, which resulted in an accident. R1, who had a history of muscle weakness, hemiplegia affecting the left side, and was at risk for falls, required assistance with transfers and was dependent on staff for moving from sitting to standing. On the day of the incident, a Certified Nurse Aide (CNA) attempted to assist R1 in pulling up his pants in the shower room without using a gait belt, which was against the facility's standard practice. During the incident, R1 was asked if he felt stable enough to stand, and he confirmed. The CNA then had R1 hold onto a grab rail with his good hand while she supported him with one hand and pulled up his pants with the other. However, R1 went dead weight, and the CNA lowered him to the floor, resulting in his left ankle twisting and causing a fracture. The resident was wearing a gripper sock on his left foot and a shoe on his right foot at the time of the fall. The facility's investigation revealed that the CNA did not utilize a gait belt during the transfer, which was expected by the facility's standard practice. The resident's care plan indicated that he required assistance from one to two staff members for transfers and was at risk for falls. Despite this, the CNA did not use a gait belt, which contributed to the resident's fall and subsequent injury.
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Illustrative
What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
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Nursing homes near Arkansas City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Arkansas City Presbyterian Manor | 0.4 mi | ★★★★★ | 12 | 0 |
| Winfield Rest Haven Ii, Llc | 11 mi | ★★★★★ | 0 | 0 |
| Winfield Senior Living Community | 11.3 mi | ★★★★★ | 0 | 0 |
| Cumbernauld Village | 12.5 mi | ★★★★★ | 2 | 0 |
| Kansas Veterans Home | 12.9 mi | ★★★★★ | 1 | 0 |
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