Medicalodges Great Bend
Inspection history, citations, penalties and survey trends for this long-term care facility in Great Bend, Kansas.
- Location
- 1401 Cherry Lane, Great Bend, Kansas 67530
- CMS Provider Number
- 175522
- Inspections on file
- 24
- Latest survey
- December 22, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Medicalodges Great Bend during CMS and state inspections, most recent first.
Several residents experienced verbal and mental abuse when a CNA made derogatory remarks about their hygiene, attempted to physically force a resident out of bed, and neglected basic care tasks. Other staff members witnessed these actions but did not promptly report them, despite being trained on abuse and neglect policies.
Staff failed to promptly report observed and suspected abuse, including aggressive and verbally abusive behavior by a CNA toward multiple residents. Several staff members witnessed or were informed of inappropriate comments, harsh treatment, and attempts to physically force a resident, but did not immediately notify administration as required by policy. The affected residents included individuals with limited alertness, some of whom showed signs of distress.
A resident with severe cognitive impairment and a history of wandering exited the facility through an unsecured, unalarmed door, traversed hazardous outdoor areas, and suffered a fall resulting in facial abrasions and a UTI. Staff did not immediately notice the resident's absence, and the door alarm was found to be nonfunctional at the time, leading to inadequate supervision and failure to prevent the elopement.
The facility failed to ensure CNAs completed the required 12-hour in-service education, with CNA N completing only three hours and CMA T lacking dementia care training. This deficiency was confirmed by the Administrative Nurse and placed residents at risk for decreased quality of care.
The facility failed to secure an oxygen storage room, leaving it accessible to wandering residents, and did not update a resident's care plan with new interventions after multiple falls. This placed residents at risk for preventable accidents and injuries.
A facility failed to maintain a medication error rate below five percent, resulting in a 7.69% error rate. A CMA administered amlodipine and benazepril to a resident despite physician orders to hold these medications if blood pressure was below 100/65 mmHg. The resident's blood pressure was 128/60 mmHg, indicating the medications should not have been given. Both the CMA and a Licensed Nurse confirmed the error, and the facility lacked a policy on medication errors.
A facility failed to ensure that a Consultant Pharmacist identified and reported repeated medication administration errors for a resident with hypertension and severely impaired cognition. Despite physician orders to hold blood pressure medications if the resident's blood pressure was below certain parameters, staff administered the medications multiple times over several months. The CP's reviews lacked notes on these irregularities, and the facility's policy for reporting such errors was not followed.
A resident with hypertension received unnecessary medications due to the facility's failure to follow physician-ordered blood pressure parameters. Despite orders to withhold amlodipine and benazepril if blood pressure was below 100/65 mm/Hg, staff administered these medications multiple times over several months when the resident's blood pressure was below the threshold. Observations and interviews confirmed the errors, and the facility lacked a medication administration policy.
Failure to Protect Residents from Verbal and Mental Abuse by CNA
Penalty
Summary
Multiple residents were subjected to verbal and mental abuse by a Certified Nurse's Aide (CNA), who made derogatory and inappropriate comments about residents' hygiene and physical condition. Witness statements documented that the CNA made repeated negative remarks about a resident's smell and food intake, used sarcasm, and laughed at another staff member's discomfort. The CNA also sternly reprimanded another resident in a public setting, causing visible distress. Additionally, the CNA was observed ranting and cussing in front of residents and expressing frustration about work assignments. Further incidents included the CNA attempting to physically force a resident out of bed against their will, despite the resident's resistance and verbal refusal. The CNA was also described as rushing through care routines, neglecting basic hygiene tasks such as brushing hair, wiping hands or faces, and changing soiled clothing. Another resident was subjected to unprofessional and hurtful comments about their cleanliness. Staff members who witnessed these actions did not immediately report the incidents to administration, with some expressing uncertainty or reluctance to escalate the situation. Licensed and certified staff interviewed after the incidents acknowledged they were trained on abuse, neglect, and exploitation (ANE) policies but failed to recognize or report the abuse at the time. Some staff rationalized their inaction by believing the incidents were isolated or that the affected residents were not alert and oriented enough to understand the abuse. The facility's policy required immediate reporting and intervention for any suspected abuse, but this protocol was not followed during the events described.
Failure to Timely Report Suspected Abuse and Aggressive Staff Behavior
Penalty
Summary
The facility failed to report suspected and observed abuse of six residents by a Certified Nurse's Aide (CNA). Multiple staff members witnessed or were aware of aggressive, verbally abusive, and unprofessional behavior by the CNA toward residents, including making derogatory comments about a resident's hygiene, speaking harshly to residents, and attempting to physically force a resident out of bed against his will. Witness statements documented that the CNA made repeated negative remarks about a resident's smell, yelled at another resident, and was generally snappy and cold toward residents during care routines. Other staff, including a Certified Medication Aide (CMA), another CNA, and a Licensed Nurse (LN), observed or were informed of these incidents but did not immediately report them to administration as required by facility policy and their training on abuse, neglect, and exploitation (ANE). Some staff expressed uncertainty or minimized the incidents, with one stating she thought it was an isolated event and another not wanting to create conflict with a coworker. The lack of timely reporting delayed the facility's awareness and response to the suspected abuse. The residents involved included individuals who were not alert and oriented, and some were visibly upset or verbally expressed distress during or after the incidents. Staff statements and facility documentation confirmed that the required immediate reporting of suspected abuse to administration and authorities did not occur as mandated by policy, resulting in a deficiency related to the timely reporting of suspected abuse, neglect, or theft.
Failure to Prevent Elopement and Ensure Door Security for Cognitively Impaired Resident
Penalty
Summary
A cognitively impaired resident with diagnoses including Alzheimer's disease, dementia, anxiety, unsteadiness, and muscle weakness, was identified as high risk for elopement and falls. The resident's care plan and assessments documented severe cognitive impairment, wandering behaviors, poor safety awareness, and a need for close monitoring and staff assistance with mobility and activities of daily living. Despite these risks, the resident was able to exit the facility through an unlocked and unalarmed door in the 200 hall, which failed to secure properly due to the alarm being unhooked, reportedly by contractors. The mag-lock on the door did not engage, allowing the resident to leave the premises unsupervised. After exiting, the resident traversed a hazardous environment, including cracked sidewalks, uneven grassy areas, a parking lot with large potholes, and several curbs. The resident ultimately fell between two apartment buildings behind the facility. The incident was discovered when a community member called 911, and facility staff identified the resident on an ambulance stretcher. The resident sustained facial abrasions and a urinary tract infection, requiring hospital evaluation and treatment. Staff statements confirmed that the resident was last seen at the nurse's station and that there was a delay in realizing the resident was missing, leading to a search and eventual discovery of the incident by observing the ambulance outside. Facility records and staff interviews revealed that the door alarm was not functioning at the time of the incident, and the required supervision and monitoring for a high-risk resident were not adequately provided. The facility's elopement policy required individualized care planning and routine security monitoring, but these measures were not effectively implemented, resulting in the resident's unsupervised exit and subsequent injury.
Removal Plan
- 1200-pound mag-locks were installed on all doors.
- The door at the end of 200 hall was secured, and the mag-lock was functioning.
- The alarm was rewired and in working order.
- All staff were re-educated on the facility's elopement policy.
- Stop signs were placed on each exit door, and the signs also requested contractors to alert staff before using the exit doors so staff could stay at the exit doors until the contractors were done.
- The facility's Elopement Book was reviewed for accuracy.
- R1 was put on one-to-one.
- The findings of the incident were taken to an emergency QAPI.
Deficiency in CNA In-Service Education
Penalty
Summary
The facility failed to ensure that Certified Nurse Aides (CNAs) completed the required 12-hour in-service education, which is necessary for maintaining the quality of care for residents. Specifically, CNA N had only completed three of the required 12 in-service hours, and CMA T lacked dementia care training. This deficiency was identified during a review of the facility's 12-hour annual in-service documentation for five certified staff members who had been employed at the facility for at least one year. The Administrative Nurse confirmed that the staff did not meet the required education topics and/or hours. Additionally, the facility was unable to provide a policy for the required services, which contributed to the deficiency and placed residents at risk for decreased quality of care.
Deficiencies in Safety and Fall Prevention
Penalty
Summary
The facility failed to maintain a secure environment free from accident hazards by not ensuring that the oxygen storage room was consistently locked. During a walkthrough, it was observed that the room containing 38 fully pressurized supplemental oxygen cylinders was unsecured, despite having a numerical keypad lock that should auto-lock when closed. Staff interviews revealed that the room should always be locked to prevent wandering residents from accessing it, but a staff member had inadvertently left it open after retrieving an oxygen bottle for a resident. Additionally, the facility did not adequately address the fall risks for a resident identified as R33, who had a history of multiple falls. R33's medical record documented several conditions, including diabetes, chronic pain, anxiety disorder, and insomnia, and noted that the resident had experienced 41 falls since admission. Despite having a care plan in place, the facility failed to update it with new interventions for 22 of these falls, as required by their risk management policy. This lack of intervention left R33 at continued risk for falls and injury. The facility's failure to secure the oxygen storage room and to implement effective fall prevention strategies for R33 highlights deficiencies in maintaining a safe environment and in managing individual resident care plans. These oversights placed residents, particularly those who are cognitively impaired and independently mobile, at risk for preventable accidents and injuries.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent, resulting in a 7.69% error rate. This deficiency was identified during a survey involving a sample of 12 residents from a total census of 37. The specific incident involved a Certified Medication Aide (CMA) administering amlodipine and benazepril to a resident, despite the physician's orders to hold these medications if the resident's blood pressure was below 100/65 mmHg. On the day of the incident, the resident's blood pressure was recorded at 128/60 mmHg, indicating that the medications should not have been administered according to the physician's parameters. The CMA later verified the physician's orders and acknowledged the error in administering the medications. A Licensed Nurse also confirmed that the medications should not have been given due to the resident's blood pressure being out of the specified parameters. The facility was unable to provide a policy related to medication errors upon request, which contributed to the deficiency. This oversight placed the resident at risk for significant medication errors and potentially affected all residents receiving medications at the facility.
Failure to Identify and Report Medication Administration Errors
Penalty
Summary
The facility failed to ensure that the Consultant Pharmacist (CP) identified and notified the facility and physician about the repeated administration of two blood pressure medications, amlodipine and benazepril, to Resident 21 when the resident's blood pressure was below the physician-ordered parameters. This occurred multiple times in April, May, June, and July 2024. The resident, who had a diagnosis of hypertension and severely impaired cognition, was dependent on staff for all activities of daily living. The physician's orders specified that the medications should be held if the blood pressure was less than 100/65 mm/Hg, but staff administered the medications despite these parameters being exceeded. The Medication Administration Record (MAR) showed that the medications were given 11 times in April, 16 times in May, 10 times in June, and 8 times in July when the blood pressure was below the specified limits. The CP's Medication Regimen Reviews for these months did not include notes on these irregularities. Observations and interviews confirmed that the medications were administered incorrectly, and the facility's policy required such findings to be communicated to the director of nursing and the medical director. However, the CP did not inform the facility of these ongoing medication errors, placing the resident at risk for unintended results from the medications.
Failure to Adhere to Blood Pressure Medication Parameters
Penalty
Summary
The facility failed to adhere to physician-ordered blood pressure parameters for a resident diagnosed with hypertension, leading to the administration of unnecessary medications. The resident, who had severely impaired cognition and required assistance for daily activities, was prescribed amlodipine and benazepril with specific instructions to hold the medications if blood pressure readings were below 100/65 mm/Hg. Despite these orders, the medications were administered multiple times over several months when the resident's blood pressure was below the specified threshold. Observations and interviews confirmed that staff repeatedly administered the medications outside the prescribed parameters. On one occasion, a Certified Medication Aide was observed administering the medications after obtaining a blood pressure reading that should have prompted withholding the drugs. Both a Licensed Nurse and an Administrative Nurse verified the ongoing medication errors, and the facility was unable to provide a medication administration policy upon request. This practice placed the resident at risk for unnecessary medications and related complications.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
