Medicalodges Arkansas City
Inspection history, citations, penalties and survey trends for this long-term care facility in Arkansas City, Kansas.
- Location
- 203 E Osage Avenue, Arkansas City, Kansas 67005
- CMS Provider Number
- 175313
- Inspections on file
- 21
- Latest survey
- June 26, 2025
- Citations (last 12 mo.)
- 14
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.
Latest citations in Kansas
Surveyors found that the facility failed to maintain sanitary food storage, handling, and dishwashing practices in the kitchen. Clean dishes were stored upright instead of inverted, and numerous food items in coolers, freezer, pantry, and spice racks were undated, missing the year, had unreadable dates, or showed visible mold, while some bags and containers were left open or unsealed. A dietary staff member handled ready-to-eat foods such as bread and butter with bare hands and repeatedly washed hands with water only, without soap or sanitizer, while preparing pureed meals for a resident. The low-heat dish machine repeatedly operated below the facility’s stated minimum wash temperature, as documented on the temperature log. These practices were inconsistent with the facility’s own food storage policy and staff’s stated expectations for glove use, labeling, sealing of food, dish storage, and dishwashing temperatures.
The facility did not employ a full-time Certified Dietary Manager (CDM) as required by its own Nutritional Services Policy, despite serving meals to 31 residents. A dietary staff member without CDM credentials was observed overseeing meal preparation, and both this staff member and an administrative nurse confirmed that the staff member was not certified, although enrolled in CDM classes. The policy specified that a CDM must oversee key functions such as menu planning, diet and diet manual with nutritional evaluations, office procedures for notifying the RD of new elders, food production, and food service, but no certified individual was fulfilling these responsibilities.
Surveyors found that the facility failed to follow professional standards for food storage and temperature monitoring. A freezer had significant ice buildup, and a refrigerator contained unlabeled, undated sliced cheese. Temperature logs for multiple freezers and refrigerators were incomplete over several days, despite policy requiring routine monitoring and documentation. The ice machine area contained extraneous items, including a plastic lid, a metal object on the floor, and a cup on the drain. In dry storage, several open food items, including pasta, noodles, gelatin, and pancake mix, were undated, unlabeled, or unsealed. Dietary staff confirmed these conditions, and the Dietary Manager later described expectations that all food be labeled, dated, and properly sealed per facility policy.
Surveyors found that staff did not consistently follow EBP, hand hygiene, and clean laundry handling practices. During tracheostomy care for a resident, a nurse wore gloves and a mask but did not don a gown or change gloves before placing clean gauze and the trach cannula. In a separate case, after completing wound care for another resident, the same nurse manipulated a suprapubic catheter tubing while still holding wound supplies and then left the room without performing hand hygiene. Additionally, a housekeeping/laundry staff member removed residents’ personal items from a covered cart and carried them over the shoulder between halls without keeping the items covered. These actions did not follow facility policies requiring targeted gown and glove use for high-contact care, proper hand hygiene around invasive devices and dressings, and keeping laundry carts covered between rooms.
A resident with hemiparesis, chronic osteomyelitis, and intervertebral disc disorder with radiculopathy experienced a fall in his room, was found on the floor near a heater with pain and bruising, and was later confirmed by mobile X-ray to have a nondisplaced fracture of the left superior pubic ramus. Despite this, the subsequent quarterly MDS documented no falls since the prior assessment and did not code the event as a fall with major injury, even though the care plan and progress notes described the fall and resulting fracture. An administrative nurse later acknowledged that the falls section of the MDS had been coded in error, contrary to facility policy and RAI manual requirements for accurate resident assessment.
A resident with severe morbid obesity, vascular dementia, anxiety, and a history of falls, but intact cognition per BIMS, was repeatedly assisted in a wheelchair by staff without foot pedals in place. On multiple observed occasions, staff pushed and turned the resident in the wheelchair while the resident held his feet off the floor and a sock was seen dragging on the floor. Interviews showed staff uncertainty and inconsistency regarding the requirement for foot pedals when assisting the resident, despite the resident’s documented fall risk and a facility falls policy requiring interventions to reduce fall risk.
A resident with Alzheimer’s disease, CKD, BPH, obstructive uropathy, and urinary retention had a suprapubic catheter that staff repeatedly secured incorrectly. During catheter care, two nurses cleaned the abdominal insertion site but attached the Stat-lock to the resident’s thigh, anchoring the tubing to the leg instead of the abdomen. Nursing leadership stated they expected leg anchoring and noted the catheter policy did not specify Stat-lock placement, even though the facility’s suprapubic catheter competency checklist explicitly directed that the tubing be secured to the abdomen.
A resident with dementia, severe cognitive impairment, and depression experienced unplanned weight loss after the RD documented a slow weight-loss trend and recommended house supplement shakes TID with added calories to meals. The facility entered and carried out the supplement order only once daily, and staff confirmed the resident received a shake only on second shift. Weight documentation showed a large, unverified increase followed by a re-weigh that demonstrated a 3.16% loss over a short period, and nursing staff did not promptly recognize or recheck the significant weight discrepancy. The RD was not informed that her TID recommendation had been effectively reduced to once daily, and the facility’s own weight-loss prevention processes were not followed.
A resident with chronic respiratory failure, a tracheostomy, and oxygen therapy orders did not have an Ambu bag or emergency tracheostomy kit readily available at the bedside, despite care plan directives for respiratory care, suctioning, and emergency response if the tracheostomy tube came out. Surveyors observed on multiple occasions that only oxygen and suction were present in the room, while the Ambu bag and emergency supplies were stored on a covered cart in the hallway under a Hoyer lift, requiring movement of equipment before use. Staff, including CNAs, an LN, and an administrative nurse, confirmed that emergency tracheostomy supplies were kept in the hallway or medication room and not at the bedside, and that they were instructed to call 911 rather than attempt reinsertion of the tracheostomy tube, even though the facility’s respiratory care policy required services in accordance with professional standards and the resident’s care plan.
A resident with diabetes, heart failure, muscle weakness, severe cognitive impairment, incontinence, and limited mobility was identified as at risk for pressure ulcers, with care plans calling for turning/repositioning, use of a pressure-reducing device, and extensive staff assistance for ADLs. Despite these documented risks and interventions, the resident, who preferred to remain in a recliner or wheelchair and became less mobile after a foot fracture requiring a walking boot, developed a facility-acquired Stage 2 pressure ulcer on the buttocks. Wound assessments showed the ulcer’s presence and progression over time, indicating that timely and effective preventive measures were not implemented in accordance with the facility’s wound assessment and prevention policy.
Unsanitary Food Storage, Handling, and Dishwashing Practices in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to maintain sanitary conditions for food storage and preparation in the kitchen. During an initial kitchen tour, they observed multiple clean containers and plates on the drying rack not inverted, leaving eating surfaces exposed. Numerous food items in the kitchen cooler, walk-in cooler, freezer, pantry, and spice rack were either undated, missing the year, had unreadable dates, or were past labeled use-by dates. Examples included cheese and ham slices with only month and day, multiple large containers of sauces, dressings, olives, cherries with visible black mold on the rim and lid, parmesan cheese, syrups, soy sauce, wing sauce, and green beans all lacking complete or legible dating. Additional findings included rusted and peeling cooler racks, open and unsealed bags of frozen foods and pantry items, and a rice bin with a handwritten prep date missing the year. Further observations showed improper food handling and hand hygiene practices by dietary staff. One dietary staff member handled ready-to-eat foods, including butter and bread for toast, with bare hands and then placed the toast on a tray for a resident. On another occasion, a partially wrapped package of cheese slices in the cooler was found without any date. The same dietary staff member was observed washing hands under running water without using soap or sanitizer on three separate occasions while pureeing food for lunch. The facility did not provide a hand hygiene policy specific to dietary staff when requested. Surveyors also reviewed the operation of the low-heat Ecolab dishwasher and its temperature logs. At the time of observation, the wash temperature was 102°F, and the April temperature log showed multiple days with wash temperatures below the documented minimum of 120°F at which the supervisor should be notified. Administrative and dietary staff later confirmed that gloves should be worn when handling ready-to-eat foods, all stored food should be sealed and labeled with month, day, and year, dishes should be inverted, and the dishwasher wash cycle should be at least 120°F. The facility’s existing Food Storage policy required staff to label all food items with the name and date opened or use-by date and to discard food past expiration, but survey findings showed these practices were not consistently followed in the kitchen.
Lack of Certified Dietary Manager Overseeing Food and Nutrition Services
Penalty
Summary
The facility failed to employ a full-time certified dietary manager (CDM) to oversee food and nutrition services for 31 residents receiving meals from the facility kitchen. On one observed noon meal, the menu consisted of shrimp, cornbread, cooked sliced squash, rice, and yellow cake with chocolate frosting, and dietary staff member BB was observed overseeing preparation of this meal in the kitchen. During an interview, dietary staff BB confirmed she was not a CDM, stating she had enrolled in but not completed the certification classes. Administrative Nurse D also verified that dietary staff BB did not have dietary manager certification, although she had started the dietary certification classes. The facility’s Nutritional Services Policy, revised 01/21/26, documented that a certified dietary manager would oversee all kitchen procedures, including menu planning, diets and the diet manual with nutritional evaluations, office procedures related to notifying the Registered Dietitian of new elders, food production, and food service, but no such certified individual was in place at the time of the survey.
Failure to Properly Label, Store, and Monitor Food and Equipment Temperatures
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage, distribution, and service practices based on observations, record review, and staff interviews. In the kitchen, a white upright freezer had approximately one-quarter inch of ice buildup along the inside and shelves, and the kitchen refrigerator contained a plastic bag of sliced yellow cheese that was unlabeled and undated. Review of March temperature logs showed missing morning and evening temperature documentation for multiple units, including a chest freezer in dry storage on numerous dates, a white stand-up freezer on several dates, a double-door refrigerator on several dates, and a single-door refrigerator on multiple dates. April logs also lacked documentation of readings for a double-door freezer on specified dates. The facility’s policies required that frozen foods be stored at 0 to -10°F, produce at 38-44°F, dairy at 35-40°F, and that temperature logs be completed and monitored by the Certified Dietary Manager or designee. Additional observations showed sanitation and labeling issues in and around the kitchen and dry storage areas. The ice machine between the kitchen and storage room had a plastic lid and a metal object on the floor behind it, and a plastic green drinking cup sitting on top of the drain underneath it. Eight 15.5-lb plastic jugs of used cooking grease were observed with numerous grayish-black substances on their tops. In dry storage, surveyors found an approximately one-quarter full 5-lb package of undated pasta Labello egg noodles, an approximately one-quarter full 4.5-lb package of unlabeled, undated, unsealed noodles, approximately three-quarters of a full package of undated strawberry gelatin, and an approximately three-quarters full bag of unsealed buttermilk pancake mix. A dietary staff member verified these findings during the survey, and the Dietary Manager later stated that staff were expected to label and date all food placed in dry storage, refrigerators, or freezers when received and when opened, and ensure items were sealed, labeled, and dated with the open date, as outlined in the facility’s written policies.
Failure to Follow Enhanced Barrier Precautions, Hand Hygiene, and Laundry Handling Practices
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective infection prevention and control program, specifically related to Enhanced Barrier Precautions (EBP), hand hygiene, and handling of clean laundry. During tracheostomy care for Resident 2, a licensed nurse performed hand hygiene, donned gloves, and wore a mask but did not don a gown as required under EBP and did not change gloves before placing clean gauze or the tracheostomy cannula. In a separate wound care observation for Resident 6, the same nurse performed hand hygiene and applied a gown and gloves before care, but after completing the wound care and while holding gauze and wound cleanser, the nurse inspected and manipulated the resident’s suprapubic catheter tubing and then left the room without performing hand hygiene. Additional deficiencies were observed in the handling of clean laundry. A housekeeping/laundry staff member placed a covered cart with residents’ personal items in one hall, then removed items from the cart and carried them over the shoulder to another hall without using the cart and without keeping the items covered between rooms. Interviews with nursing and administrative staff confirmed that wound care supplies should be kept in residents’ rooms or bagged and taken to the wound nurse, that hand sanitizing should be performed before and after wound care and after contact with catheters or tubing, and that staff are expected to wear gown, gloves, and mask at minimum for EBP. The housekeeping supervisor also stated that laundry staff are expected to keep the cart covered between rooms. These practices did not align with the facility’s written policies on EBP and hand hygiene, which require targeted gown and glove use during high-contact care and hand cleansing before and after resident contact, after contact with blood or body fluids, after removing PPE, and before procedures involving invasive devices or dressing care.
Inaccurate MDS Coding of Fall With Major Injury
Penalty
Summary
The deficiency involves the facility’s failure to accurately complete the Minimum Data Set (MDS) assessment for Resident 13, resulting in an incorrect coding of the resident’s fall history and injury status. Resident 13’s electronic medical record documented multiple diagnoses, including hemiparesis/hemiplegia, chronic osteomyelitis, and intervertebral disc disorder with radiculopathy. The quarterly MDS dated 03/24/26 recorded a Brief Interview for Mental Status (BIMS) score of 15, indicated the resident required supervision for walking 10 feet and partial assistance for walking 50 feet, and documented that the resident had no falls since the previous MDS assessment. However, this conflicted with clinical documentation and the resident’s care plan and progress notes. On 01/16/26, progress notes showed that staff responded to the resident’s call light and found him on the floor next to his heater, lying on boxes, papers, and his bedside table. The resident complained of back and left hip pain, had swelling behind his left ear from hitting the heater, redness on his left cheek, and reported tenderness with weight-bearing on his leg. A mobile X-ray later confirmed a nondisplaced fracture of the left superior pubic ramus, and the provider assessed the resident the same day. The care plan documented that the resident continued to act independently despite education to use the call light, and the resident later reported to therapy staff that he had falls and was working to get stronger after his last fall. During interviews, an administrative nurse acknowledged that the resident had a fall resulting in a hip fracture that should have been coded on the MDS as a fall with major injury, and that the falls section of the MDS had been coded in error, contrary to the facility’s policy to complete the MDS according to federal regulations and the RAI manual.
Failure to Use Wheelchair Foot Pedals When Assisting a Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide an environment free of accident hazards by not ensuring the use of wheelchair foot pedals when staff assisted a resident in a wheelchair. The resident had diagnoses including severe morbid obesity, vascular dementia, anxiety, and noncompliance, and had a BIMS score of 15 on multiple MDS assessments, indicating intact cognition. The resident’s assessments and Falls Care Area Assessment documented a history of falls within the previous months and identified the resident as being at risk for falls. The care plan documented that the resident was at risk for falls, had experienced a fall, and that his back locked up at times requiring the use of a wheelchair. On one observed occasion, a CNA pushed the resident in a wheelchair without foot pedals attached as he was brought from outside smoking back to his room, during which the resident crossed and held his feet off the floor. On another observed occasion, a nurse turned the resident in his wheelchair and assisted him to the dining room without foot pedals, during which the resident’s sock was half off and dragged on the floor, and the resident again held his foot off the floor. During interviews, one nurse expressed uncertainty about whether the resident should be assisted in the wheelchair without foot pedals, while a CMA stated the resident used foot pedals when being assisted but not when self-propelling. Administrative nursing staff confirmed that staff should not assist the resident in the wheelchair without foot pedals. The facility’s falls policy stated that residents would be assessed for fall risks and interventions implemented to reduce those risks.
Improper Securing of Suprapubic Catheter Tubing
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate care and treatment for a resident with a suprapubic catheter by not securing the catheter tubing according to current standards of practice and the facility’s own competency checklist. The resident had multiple urologic and cognitive conditions, including Alzheimer’s disease with severely impaired cognition (BIMS score of four), chronic kidney disease stage three, benign prostatic hyperplasia, obstructive uropathy, and urinary retention, and was documented as having an indwelling catheter. The care plan included an order from the resident’s urologist directing staff not to remove the catheter and directed staff to apply Skin-prep prior to attaching a Stat-lock for the suprapubic catheter. On two separate observations, licensed nurses assessed and cleaned the suprapubic catheter site on the resident’s abdomen but attached the Stat-lock to the resident’s left upper thigh, securing the tubing from the abdomen to the leg. One nurse confirmed the Stat-lock was attached to the thigh and stated they were unaware that a Stat-lock could be adhered to the abdomen. The administrative nurse stated she expected the Stat-lock to be anchored to the leg and acknowledged that the facility catheter policy did not specify Stat-lock placement for a suprapubic catheter. However, she also stated that the facility’s suprapubic catheter replacement competency checklist, which she had previously reviewed, directed that the catheter tubing should be anchored to the abdomen. The competency checklist documented that the catheter tubing should be secured to the abdomen, but this was not followed in practice.
Failure to Implement Dietitian’s TID Supplement Order and Validate Significant Weight Changes
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate nutritional maintenance for Resident 27 by not implementing the registered dietitian’s recommendation for house supplement shakes three times daily and by not appropriately monitoring and validating significant weight changes. Resident 27 had dementia with severe cognitive impairment, chronic pain, unspecified intellectual disabilities, and major depressive disorder, used a wheelchair, and required set-up or clean-up assistance for eating. The MDS documented a weight of 123 lbs with no weight loss or gain at that time, and the care plan included nutrition-focused interventions such as providing diet as ordered, snacks between meals, monitoring for loss of appetite while on Remeron, and providing supplements as ordered. On 03/03/26, the dietitian documented that the resident had slow, unplanned weight loss related to a decline in energy and recommended offering a house supplement three times a day and adding extra sugar, cream, and butter to foods and fluids to increase energy intake and promote weight stability. Despite this recommendation, the electronic task list from 03/16/26 to 04/13/26 showed the resident was only offered and received a supplement drink once daily in the afternoon. Staff interviews confirmed that the resident received a supplement only on second shift around 2:00 PM, and an administrative nurse acknowledged she had missed the dietitian’s TID recommendation and entered the order for only once daily. Weight records showed a documented weight of 123.4 lbs on 04/01/26 and an implausible weight of 168.0 lbs on 04/10/26, which was not recognized or rechecked at the time by nursing staff. A subsequent re-weigh on 04/15/26, using the wheelchair tare method, yielded a resident weight of 119.5 lbs, reflecting a 3.9 lb (3.16%) loss from 04/01/26. Administrative staff later stated that the 168 lb weight should have been immediately reported and rechecked, and that whoever weighed the resident should have reviewed the previous weight and performed a re-weight if there was a significant change. The facility’s weight loss prevention policy required nutritional interventions and RD consultation for residents with poor or declining intake or weight loss, but the RD was not informed that her TID supplement recommendation had been effectively reduced to once daily.
Emergency Tracheostomy Equipment Not Readily Available at Bedside
Penalty
Summary
The deficiency involves the facility’s failure to ensure that emergency respiratory equipment, specifically an Ambu bag, was readily available at the bedside for a resident with a tracheostomy in the event of accidental extubation or respiratory distress. The resident had diagnoses including sleep apnea, chronic respiratory failure with hypoxia, obesity, dysphagia, malignant neoplasm of the nasopharynx, and required oxygen therapy and tracheostomy care. The resident was cognitively intact, used a wheelchair, and required varying levels of assistance with ADLs. The care plan documented that the resident received breathing treatments, required staff reminders to notify them when treatments were finished, and that staff were to provide oxygen via tracheostomy mask and suction as indicated. The care plan and physician orders also directed staff to call 911 and send the resident to the ER if the entire tracheostomy tube came out, and to follow the facility’s Emergency Protocol Health policy. Surveyor observations on multiple occasions showed that while oxygen and suction were available at the bedside, there was no Ambu bag in the resident’s room. Instead, the Ambu bag and emergency supplies were stored on a covered cart in the hallway under a Hoyer lift, with a battery charger on top, requiring staff to move equipment and wheel the cart into the room before use. Staff interviews confirmed that the emergency tracheostomy supplies and Ambu bag were not kept at the bedside and were instead located in the hallway or medication room. Nursing staff stated that all nurses were CPR-qualified and that hospice residents with tracheostomies had bedside emergency kits because hospice provided them. An administrative nurse reported that tracheostomy care competencies were done annually and explained that there was no emergency kit or Ambu bag at the bedside because the physician had instructed staff not to reinsert the tracheostomy if it came out, but to call 911 immediately. The facility’s Respiratory Care policy stated that necessary respiratory care and services would be provided in accordance with professional standards of practice, the resident’s care plan, and resident choice.
Failure to Implement Timely Interventions to Prevent Facility-Acquired Pressure Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to initiate timely and adequate interventions to prevent the development and progression of a pressure ulcer for Resident 27, who was identified as at risk for pressure ulcer development. The resident had multiple diagnoses including diabetes mellitus, osteoarthritis, heart failure, and muscle weakness, and had a BIMS score of five indicating severely impaired cognition. Assessments documented that the resident required extensive assistance of one to two staff for bed mobility, personal hygiene, dressing, repositioning, and transfers, and that she had a urinary catheter for constant urinary retention and incontinence. The MDS and care plans identified the resident as at risk for skin impairment, with a history of refusing to lie down to relieve pressure from the buttocks, and indicated she was on a turning/repositioning program with nutritional or hydration interventions and a pressure-reducing device in her chair. A Braden Scale score of 16 further indicated risk for pressure ulcer development. Despite these identified risks and care plan directives, the resident developed a facility-acquired Stage 2 pressure ulcer on the left buttocks. Weekly wound assessments documented the presence and progression of an open area on the left buttocks, with measurements changing over time, including a lateral opening measuring 2.0 cm by 1.0 cm and later a left inner buttocks wound measuring 3.0 cm by 2.0 cm by 0.5 cm depth, and then 2.0 cm by 3.5 cm by 0.8 cm depth. The record noted that the resident became less mobile after sustaining a left 5th metatarsal fracture requiring a walking boot, and that she was incontinent and preferred to sit in a recliner and wheelchair rather than sleep in bed. The facility’s own Wound Assessment, Prevention and Treatment policy required timely skin assessments, Braden evaluations, and immediate implementation of plans to reduce pressure ulcer risk, but the development of a facility-acquired pressure ulcer under these known risk conditions demonstrated that timely preventive interventions were not effectively implemented.
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