Mennonite Friendship Communities Inc
Inspection history, citations, penalties and survey trends for this long-term care facility in South Hutchinson, Kansas.
- Location
- 600 W Blanchard Avenue, South Hutchinson, Kansas 67505
- CMS Provider Number
- 175379
- Inspections on file
- 20
- Latest survey
- August 26, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Mennonite Friendship Communities Inc during CMS and state inspections, most recent first.
A resident with complex medical needs was involuntarily discharged for non-payment, but the facility failed to provide a discharge notice containing required information such as appeal rights, discharge location, and state agency contacts. The resident's EHR also lacked proper documentation of the discharge reason, and facility policies did not address all necessary discharge procedures.
The facility failed to secure an activated steam table and a beverage station, leaving them accessible to residents. The steam table, with high water temperatures, was left unattended in an unlocked closet, and the beverage station gate was left open without staff supervision. These actions placed cognitively impaired, independently mobile residents at risk for preventable accidents.
A resident with diabetes mellitus had multiple instances of blood sugar levels exceeding physician-ordered parameters, yet the facility failed to notify the physician as required. Despite having a care plan and guidelines in place, the nursing staff did not adhere to the directive to report significant changes in the resident's condition, placing the resident at risk for hyperglycemic and hypoglycemic episodes.
The facility failed to ensure that the MDS assessments for two residents were properly transmitted and received by CMS. One resident's comprehensive MDS was completed but not submitted, while another's quarterly MDS was submitted but not received. A licensed nurse confirmed the oversight, acknowledging her responsibility for ensuring submissions were completed and accepted, contrary to the facility's policy requiring transmission within seven days.
A deficiency was identified when a nurse failed to verify the placement of a G-tube before administering medications and nutritional feeding to a resident with dysphagia and cerebral infarct. This action was against the facility's policy and physician's orders, placing the resident at risk for complications.
The facility failed to ensure appropriate medication use and documentation for two residents. A resident received Seroquel without an appropriate diagnosis, and the CP did not ensure a specific stop date for PRN Ativan. Another resident was prescribed Risperdal without a documented rationale, and the facility did not follow the CP's recommendation for a dose reduction. These failures placed residents at risk for inappropriate medication use.
A resident with diabetes mellitus had multiple instances of blood sugar levels outside the physician-ordered parameters, yet the facility failed to notify the physician as required. Despite having orders to report blood sugar levels less than 90 ml/dl or greater than 300 ml/dl, the facility did not contact the physician on several occasions, placing the resident at risk for complications.
The facility failed to ensure appropriate physician-documented rationales for the use of antipsychotic medications for two residents. One resident received Seroquel without an approved diagnosis or documented risks versus benefits, and the PRN Ativan lacked a proper stop date. Another resident continued to receive Risperdal without a documented rationale, despite recommendations for a gradual dose reduction. These oversights placed the residents at risk for unnecessary medication use.
A resident with Alzheimer's and major depressive disorder experienced a medication administration error when the facility failed to follow a physician's order to decrease the dosage of Risperdal. The resident received an incorrect dosage for four days, as the Medication Administration Record was not updated in accordance with the facility's policy, placing the resident at risk for adverse effects.
A facility failed to coordinate care between the facility and a hospice provider for a resident with COPD and severe cognitive impairment receiving hospice services. The resident's care plan lacked specific instructions on hospice services, including support visits, supplies, and medications. This deficiency was verified by an administrative nurse, placing the resident at risk for inadequate end-of-life care.
Deficient Involuntary Discharge Notice and Documentation
Penalty
Summary
The facility failed to ensure that the involuntary discharge notice provided to a resident or their representative included all required information. Specifically, the notice did not contain a statement of appeal rights, the location to which the resident would be discharged, or the contact information for the required state agencies. Additionally, the notice did not provide instructions on how to initiate or submit an appeal. The letter did include contact information for the long-term care ombudsman and a list of local LTC facilities, but omitted other regulatory requirements. The notice was issued due to non-payment of services, with documentation indicating the resident had been denied Medicaid services for failure to submit required paperwork. Further review revealed that the resident's electronic health record did not contain a physician order to discharge, although a scanned order was present in the resident documents. The facility's policy on admission, transfer, and discharge referenced compliance with regulations and documentation of the reason for discharge in the clinical record, but did not address providing a written discharge summary, recapitulation of stay, or medication reconciliation to the resident or their representative. The resident involved had significant medical needs, including respiratory failure with hypoxia, hypothyroidism, weakness, and required assistance with personal care.
Failure to Secure Steam Table and Beverage Station
Penalty
Summary
The facility failed to maintain a safe environment free from accident hazards, as evidenced by an activated steam table being left unattended and unsecured in an unlocked closet in the 100-hall dining room. The steam table, with water temperatures reaching up to 160.1 degrees Fahrenheit, was accessible to residents due to an unlocked gate. Staff members, including a Certified Nurse Aide and a Certified Dietary Manager, were unaware of who was responsible for securing the gate, and the steam table was left unsupervised while residents were present in the dining room. This oversight was contrary to the facility's policy, which mandates that steam tables must be continually staffed and never left unattended in areas accessible to residents. Additionally, the facility failed to secure a beverage station, which included a hot chocolate machine and a coffee dispenser with temperatures as high as 160 degrees Fahrenheit. The gate to the beverage station was left open without staff supervision, leaving it accessible to residents. The facility's policy requires that hot beverage equipment be placed in safe areas and that security gates be closed when staff are not present to monitor access. These lapses in supervision and security placed eight cognitively impaired, independently mobile residents at risk for preventable accidents or injuries.
Failure to Notify Physician of Blood Sugar Irregularities
Penalty
Summary
The facility failed to notify the physician when a resident's blood sugar levels were outside the physician-ordered parameters. The resident, who had diagnoses of diabetes mellitus, depression, and anxiety, was supposed to have their blood sugar levels monitored and reported to the physician if they fell below 90 ml/dl or exceeded 300 ml/dl. Despite this directive, there were multiple instances documented in December 2024 and January 2025 where the resident's blood sugar levels exceeded the upper limit, yet the physician was not notified. This oversight was confirmed by a licensed nurse who acknowledged the failure to contact the physician as required. The resident was actively managing their blood sugar routines with the assistance of a Dexcom blood glucose monitoring machine and received insulin daily. The facility's guidelines mandated that clinical care problems and significant changes in a resident's condition be communicated to the physician in a timely manner. However, the nursing staff did not adhere to these guidelines, resulting in a lack of timely physician involvement. This placed the resident at risk for hyperglycemic and hypoglycemic episodes due to the delayed notification of the physician.
Failure to Transmit MDS Data to CMS
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments for two residents were properly transmitted and received by the Center for Medicare and Medicaid Services (CMS). Specifically, the comprehensive MDS for one resident was completed and signed but not submitted, while the quarterly MDS for another resident was submitted but not received by CMS. This issue was confirmed by a licensed nurse who acknowledged her responsibility for ensuring the MDS submissions were completed and accepted. The facility's policy required that MDS data be transmitted within seven days of completion, which was not adhered to in these cases.
Failure to Verify G-Tube Placement Before Administration
Penalty
Summary
A deficiency was identified in the care of a resident with a G-tube at the facility. The resident, who had a diagnosis of dysphagia and cerebral infarct, required a feeding tube for nutritional maintenance. The care plan specified that staff should assess tube placement, patency, and residual before and after meals and medication administration. However, during an observation, a licensed nurse failed to check the placement of the G-tube before administering medications and nutritional feeding to the resident. The facility's policy on enteral tube use and care required verification of tube placement by aspirating stomach contents before administering feedings or medications. Despite this, the nurse administered medications and nutritional supplements without confirming the tube's placement, which was against the physician's orders and the facility's policy. This oversight placed the resident at risk for complications related to the feeding tube.
Failure to Ensure Appropriate Medication Use and Documentation
Penalty
Summary
The facility failed to ensure that the Consultant Pharmacist (CP) identified and reported the lack of an appropriate indication for the use of Seroquel, an antipsychotic medication, for Resident 38. The CP's monthly medication review noted that the resident received Seroquel for depression, which was not an acceptable diagnosis for the medication. Despite the CP's request for a different diagnosis or a reduction in medication, the physician did not provide an appropriate rationale or indication for the continued use of Seroquel. Additionally, the CP failed to ensure a specific 14-day stop date for Resident 38's PRN Ativan, an antianxiety medication, which was required by the facility's policy. For Resident 27, the facility did not follow the CP's recommendation to obtain the physician's rationale for the continued use of the antipsychotic Risperdal, prescribed for dementia with behaviors. The CP requested clarification of the diagnosis and documentation of what had been tried and failed, but the physician did not provide a rationale for the continued use of Risperdal. The facility's records showed that the resident had no documented behaviors that would justify the use of Risperdal, and the medication was not reduced as recommended by the CP. The facility's policies required the CP to document drug regimen reviews and report any irregularities to the attending physician, medical director, and director of nursing. However, the CP did not consistently report irregularities, such as the lack of appropriate diagnoses for antipsychotic medications and the absence of a specific stop date for PRN medications. This failure placed the residents at risk for inappropriate use of medication and related complications.
Failure to Notify Physician of Blood Sugar Levels Outside Parameters
Penalty
Summary
The facility failed to notify the physician of blood sugar levels outside of the ordered parameters for a resident diagnosed with diabetes mellitus, depression, and anxiety. The resident, who had intact cognition and was independent in most activities of daily living, was managing his blood sugar routines with the help of a Dexcom continuous glucose monitor. Despite having clear physician orders to notify the physician if blood sugar levels were less than 90 ml/dl or greater than 300 ml/dl, the facility did not contact the physician on multiple occasions when the resident's blood sugar levels exceeded these parameters. The resident's blood sugar levels were documented as being out of the specified range on several dates in December 2024 and January 2025, yet the physician was not notified. Licensed Nurse G acknowledged the oversight and confirmed that the physician should have been contacted. The facility's guidelines and blood glucose monitoring policy required staff to communicate significant changes in a resident's condition to the physician, but this protocol was not followed, placing the resident at risk for complications and adverse effects related to medications.
Failure to Document Rationale for Antipsychotic Use
Penalty
Summary
The facility failed to ensure that two residents, R38 and R27, had appropriate physician-documented rationales for the use of antipsychotic medications, Seroquel and Risperdal, respectively. For R38, the facility did not provide an approved diagnosis or a documented rationale that included the risks versus benefits for the use of Seroquel. Additionally, the facility did not ensure a 14-day stop date for the PRN Ativan, which was incorrectly documented with a stop date of 01/01/2035. This oversight placed R38 at risk for unnecessary medication use and related complications. R38's medical records indicated diagnoses of dementia without behavior disturbance, anxiety, and depression. Despite receiving multiple medications, including an antipsychotic, the records lacked evidence of a physician-documented rationale for Seroquel. Observations and interviews revealed that R38 could be rude and had some behaviors, but there was no clear documentation supporting the necessity of Seroquel. The facility's policy required that psychotropic medications be prescribed only when indicated by assessment and medical necessity, with a clear diagnosis or condition documented, which was not adhered to in R38's case. For R27, the facility also failed to obtain a physician's rationale for the continued use of Risperdal for dementia with behaviors. The resident's records showed a history of Alzheimer's disease and recurrent major depressive disorder, with documented verbal behaviors. Despite recommendations from the consultant pharmacist for a gradual dose reduction and clarification of the diagnosis, the facility did not provide a rationale for the continued use of Risperdal. The facility's policy required a gradual dose reduction and behavioral interventions unless clinically contraindicated, which was not properly documented or followed for R27.
Medication Administration Error for Resident with Alzheimer's and MDD
Penalty
Summary
The facility failed to adhere to physician orders when administering medication to Resident 27, resulting in a medication error that persisted for four days. Resident 27, who has diagnoses of Alzheimer's disease and recurrent major depressive disorder, was supposed to have their Risperdal dosage reduced according to a physician order dated January 10, 2025. However, the Medication Administration Record (MAR) did not reflect this change, and staff continued to administer the previous dosage of 0.5 mg twice daily from January 11 to January 14, 2025, which was four doses more than ordered. The error was identified when a licensed nurse verified that the MAR had not been updated to reflect the physician's order to decrease the Risperdal dosage. The facility's Medication Administration policy requires staff to review new medication orders and implement them within 24 hours, which was not followed in this case. This oversight placed Resident 27 at risk for adverse effects from the medication, as the facility did not follow the physician's directive to decrease the dosage.
Failure to Coordinate Hospice Care for Resident
Penalty
Summary
The facility failed to ensure coordinated care and services between the facility and the hospice provider for a resident receiving hospice services. The resident, identified as R41, had a diagnosis of Chronic Obstructive Pulmonary Disease (COPD) and dysphagia, and was documented to have severe cognitive impairment. The resident's care plan indicated a terminal prognosis and the need for hospice services, directing staff to provide comfort and observe for signs of pain. However, the care plan lacked specific instructions on the services provided by hospice, including the frequency and type of support visits, supplies, medical equipment, medications covered by hospice, and hospice contact information. The facility's policy on hospice services outlined the need for an individualized plan of care developed before hospice care begins, which should include an assessment of the resident's and family's needs for services. Despite this, the facility did not have a coordinated care plan with the hospice provider, as verified by Administrative Nurse D. This lack of coordination placed the resident at risk for inadequate end-of-life care, as the facility did not ensure the integration of care and services provided by both the facility and the hospice provider.
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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