Onaga Operator, Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Onaga, Kansas.
- Location
- 500 Western Street, Onaga, Kansas 66521
- CMS Provider Number
- 175220
- Inspections on file
- 18
- Latest survey
- July 28, 2025
- Citations (last 12 mo.)
- 1 (1 serious)
Citation history
Health deficiencies cited at Onaga Operator, Llc during CMS and state inspections, most recent first.
The facility failed to ensure that a resident was protected from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, due to inadequate protective measures and oversight.
The facility did not employ a full-time certified dietary manager for its 25 residents, risking inadequate nutrition. Dietary Staff BB, who was overseeing meal preparation, lacked the necessary certification, as confirmed by Administrative Nurse D. The facility's policy required a qualified nutritional professional if a dietitian was not full-time, which was not met.
The facility failed to ensure a sanitary environment by not monitoring washing machine temperatures, crucial for eliminating infectious pathogens. Staff interviews revealed confusion over responsibilities, with neither laundry nor maintenance staff checking temperatures. This non-compliance with facility policy placed residents at risk of infection.
The facility failed to provide written notice to residents or their representatives and did not notify the LTCO when residents were transferred to the hospital. This deficiency affected four residents, each transferred without the required notifications, placing them at risk of uninformed care choices and impaired rights.
A resident with a history of constipation was not provided with a comprehensive care plan to prevent constipation, despite having a diagnosis and frequent bowel incontinence. The care plan lacked specific interventions, leading to severe constipation and hospital admission. Observations and interviews confirmed the absence of necessary interventions, violating the facility's policy for comprehensive care plans.
The facility's Consultant Pharmacist failed to identify and report medication irregularities for several residents, including inappropriate indications for antipsychotic medication and the absence of stop dates for antianxiety medications. This oversight placed residents at risk for unnecessary medication side effects.
The facility failed to ensure appropriate indications and documentation for psychotropic medications for several residents, leading to deficiencies in medication management. A resident with dementia and other mental health issues received antipsychotic and antianxiety medications without documented nonpharmacological interventions or a risk versus benefit analysis. Another resident with depression received lorazepam without a required stop date, and a third resident with anxiety had a similar issue with Ativan. Staff were aware of the requirements but faced challenges in obtaining compliance from physicians.
A resident on a pureed diet did not receive a complete meal as the dietary staff failed to prepare and offer pureed bread, believing it would be soggy and unappetizing. This decision was made without the necessary approval from a physician or clinical dietician, violating the facility's policy and placing the resident at risk for impaired nutrition.
A resident received ten times the prescribed dose of metolazone due to a misreading of the handwritten order by a nurse. The error was compounded by the failure to use the EMR template and ignoring dose warnings. The resident was hospitalized for critically low potassium levels as a result.
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 protective measures and oversight.
Failure to Employ Certified Dietary Manager
Penalty
Summary
The facility failed to employ a full-time certified dietary manager for its 25 residents, which placed them at risk for inadequate nutrition. During an observation of the noon meal preparation, it was noted that Dietary Staff BB was overseeing the process. However, upon further inquiry, it was confirmed that Dietary Staff BB was not a certified dietary manager, although he had started taking the necessary classes. This lack of certification was verified by Administrative Nurse D. The facility's Food Service Staffing Policy, revised in October 2023, required that if a dietitian was not employed full-time, another qualified nutritional professional should serve as the dietary manager. This individual must meet specific qualifications, such as being a certified dietary manager or having equivalent credentials or experience. The facility's failure to adhere to this policy by not employing a qualified dietary manager compromised the nutritional services provided to the residents.
Inadequate Laundry Practices Risk Infection Spread
Penalty
Summary
The facility failed to maintain a sanitary environment to prevent the transmission of communicable diseases and infections due to inadequate laundry practices. Observations revealed that staff did not monitor or record the washing machine water temperatures, which is crucial for eliminating infectious pathogens. Housekeeping staff indicated that the facility had high-temperature washing machines, but the laundry staff did not check or record the hot water temperatures. Additionally, clothing and bedding from residents on Enhanced Barrier Precautions were washed with other residents' laundry, potentially increasing the risk of infection spread. Interviews with staff highlighted a lack of clarity regarding responsibilities for monitoring washing machine temperatures. The Administrative Nurse stated that either laundry or maintenance staff should be checking and recording these temperatures daily. However, the Maintenance Staff confirmed that he did not check the washing machine's hot water temperatures, focusing instead on monitoring waterborne pathogens in other areas. The facility's policy required handling all laundry as contaminated and specified temperature guidelines for effective pathogen elimination, which were not adhered to, placing residents at risk of infection.
Failure to Notify Residents and Ombudsman of Hospital Transfers
Penalty
Summary
The facility failed to provide timely written notice to residents or their representatives regarding facility-initiated transfers to the hospital, as well as failing to notify the Office of the Long-Term Care Ombudsman (LTCO). This deficiency was identified for four residents, each of whom was transferred to the hospital without the required notifications. The facility's policy, dated October 2022, mandates that residents and/or their representatives receive written notice of the reason for transfer or discharge, and a copy of this notice should be sent to the LTCO. However, this policy was not followed in the cases of the residents reviewed. Resident 16, who had multiple medical conditions including atrial fibrillation and heart failure, was transferred to the hospital without written notice being provided to her or her representative, nor was the LTCO notified. Similarly, Resident 24, with severe cognitive impairment and a history of falls, was also transferred without the required notifications. In both cases, the facility's failure to adhere to its own policy placed the residents at risk of uninformed care choices and impaired rights. Additionally, Resident 4, who had intact cognition and a history of chest pain, and Resident 26, who was independent with most activities of daily living, were transferred to the hospital without written notice to them or their representatives, and without notifying the LTCO. The facility's administrative nurse and social service designee confirmed the lack of notification, citing unawareness of the requirement. This systemic failure to provide necessary notifications highlights a significant deficiency in the facility's adherence to regulatory requirements.
Failure to Develop Comprehensive Care Plan for Constipation Prevention
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident with a history of constipation, which led to a deficiency in care. The resident, who had a diagnosis of constipation and was frequently incontinent of bowel, had a care plan that lacked specific interventions to prevent constipation. Despite having intact cognition and being independent with most activities of daily living, the resident experienced severe constipation, which was documented in progress notes. These notes indicated that the resident had difficulty having bowel movements, requested stool softeners, and experienced severe straining with small rectal bleeding, ultimately leading to hospital admission for constipation and hypotension. Observations and interviews with administrative nurses confirmed the absence of necessary interventions in the resident's care plan to address constipation. The facility's policy required comprehensive care plans with measurable objectives and time frames to meet residents' needs, but this was not adhered to in the case of the resident. The lack of a detailed care plan placed the resident at risk for impaired care due to uncommunicated care needs, as evidenced by the resident's hospitalization for constipation.
Consultant Pharmacist Fails to Report Medication Irregularities
Penalty
Summary
The facility failed to ensure that the Consultant Pharmacist (CP) identified and reported medication irregularities for several residents, leading to deficiencies in medication management. Specifically, the CP did not report the inappropriate indication for Seroquel, an antipsychotic medication, prescribed to a resident with dementia and other behavioral disturbances. The resident's electronic medical record lacked documentation of a physical rationale, including unsuccessful attempts for nonpharmacological symptom management and a risk versus benefit analysis for the continued use of Seroquel. Additionally, the CP failed to address the absence of a stop date for the resident's as-needed lorazepam, an antianxiety medication, despite the physician's refusal to include one. Another resident with diagnoses of depression and adjustment disorder was prescribed lorazepam as needed for anxiety and restlessness, but the order lacked a stop date. The CP's drug regimen reviews over several months did not address this issue. Interviews with facility staff revealed awareness of the requirement for a stop date, but the physician did not comply, and the CP did not document this omission in the monthly reviews. This oversight placed the resident at risk for inappropriate use of antianxiety medication. A third resident with an anxiety disorder was prescribed Ativan, another form of lorazepam, with an indefinite stop date. The CP's regimen reviews from May to September did not identify or report the lack of a stop date or specified duration for the medication. The facility was unable to provide a policy regarding CP regimen reviews, indicating a systemic failure to ensure proper medication management and oversight, which placed residents at risk for unnecessary medication side effects.
Deficiencies in Psychotropic Medication Management
Penalty
Summary
The facility failed to ensure appropriate indications and documentation for the use of psychotropic medications for several residents, leading to deficiencies in medication management. Resident 19, who had diagnoses of dementia, anxiety, depression, and bipolar disorder, was receiving antipsychotic and antianxiety medications without documented unsuccessful attempts for nonpharmacological interventions or a risk versus benefit analysis. The physician's order for lorazepam lacked a 14-day stop date, which is required by the facility's policy. Observations revealed that Resident 19 frequently yelled out, and staff were aware of the need for a stop date but were unable to obtain one from the physician. Similarly, Resident 7, with diagnoses of depression and adjustment disorder, was receiving lorazepam without a stop date. The resident's care plan included monitoring for side effects and behaviors, but the physician's order did not comply with the facility's policy of limiting PRN orders to 14 days. Staff acknowledged the requirement for a stop date but faced challenges in getting the physician to comply. The lack of a stop date for the PRN lorazepam placed the resident at risk for adverse side effects. Resident 23, diagnosed with an anxiety disorder, also had a physician's order for PRN Ativan without a stop date. The facility's policy mandates a 14-day limit on PRN orders for antianxiety medications unless extended with proper documentation. Administrative staff confirmed the absence of a stop date and the difficulty in obtaining one from the physician. This oversight in medication management placed Resident 23 at risk for unnecessary psychotropic medication use.
Failure to Provide Complete Pureed Diet
Penalty
Summary
The facility failed to provide a nourishing, well-balanced diet to a resident who was on a pureed diet. During an observation, it was noted that the dietary staff prepared a pureed meal for the resident by blending a slice of meatloaf and mixed vegetables to the consistency of mashed potatoes. However, the dietary staff did not prepare or offer pureed bread to the resident, as they believed the resident would not eat it due to its soggy texture. This decision was made without approval from a physician or clinical dietician, as required by the facility's Therapeutic Diets Policy. The facility's policy, revised in October 2023, mandates that residents on therapeutic diets should not receive modifications that are not part of the diet unless approved by a physician in conjunction with a clinical dietician. The failure to provide the pureed bread, which is part of the grain group, resulted in the resident not receiving a complete and balanced meal, placing them at risk for impaired nutrition. This deficiency was identified through observation, record review, and interviews with dietary staff.
Significant Medication Error Due to Misreading of Prescription
Penalty
Summary
The facility failed to ensure a resident remained free from significant medication errors. The resident returned from a cardiology appointment with a new order for metolazone, a diuretic, at a dose of 2.5 mg. However, Licensed Nurse (LN) G misread the order as 25 mg and instructed LN H to administer five 5 mg tablets from the resident's PRN stock. This resulted in the resident receiving ten times the prescribed dose. When the pharmacy delivered the correct medication dose of 2.5 mg a few hours later, LN G realized the error and contacted the resident's cardiologist. The cardiologist ordered monitoring for depleted fluid volume and a basic metabolic panel (BMP) the next day. The BMP revealed critically low potassium levels, leading to the resident's hospitalization for intravenous fluids and potassium supplementation. The resident's potassium levels remained critically low for several days, necessitating continued medical intervention. The root cause analysis identified that LN G incorrectly read the handwritten order and did not use the electronic medical record (EMR) template, which would have provided an alert for the excessive dose. Additionally, LN H, who administered the medication, did not notice the dose warning in the EMR. Both nurses failed to wait for the pharmacy to deliver the correct medication, opting instead to use the resident's PRN stock, which contributed to the significant medication error.
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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