Richmond Healthcare & Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Richmond, Kansas.
- Location
- 340 E South Street, Richmond, Kansas 66080
- CMS Provider Number
- 175444
- Inspections on file
- 20
- Latest survey
- March 23, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Richmond Healthcare & Rehab Center during CMS and state inspections, most recent first.
A resident with stroke, dementia, and dysphagia was care planned as needing monitoring for chewing and swallowing problems and was admitted on a CCHO/LCS diet with regular texture. After episodes of coughing and difficulty swallowing meat, SLP evaluated the resident, and a FEES study recommended a minced and moist mechanical soft diet, medications in puree, upright positioning during and after meals, and double-swallow strategies. SLP documentation later described the resident as on a mechanical soft diet with thin liquids and pills crushed in puree, requiring total supervision at meals, but the EMR contained only an ongoing order for a regular-texture CCHO/LCS diet with no documented diet changes. The swallow study was scanned into the EMR under a miscellaneous tab without an alert, there was no documented provider notification or response, and the nurse who reported calling the provider and being told to continue the regular diet did not enter a progress note. Staff interviews showed uncertainty about how SLP recommendations and test results were communicated and processed, and no relevant policy was provided.
A CNA employed for over a year did not have a required annual performance evaluation completed, as confirmed by the administrative nurse responsible for staff reviews. Facility policy mandates yearly evaluations to guide in-service training and compliance, but this process was not followed for the CNA working night shifts.
The facility did not employ a full-time certified dietary manager, as required by its policy, to oversee food and nutrition services for 47 residents. Administrative staff confirmed the absence of a certified dietary manager, and dietary staff reported lacking certification and only receiving monthly visits from the dietary manager.
Surveyors found that during ongoing dining room construction, there were no barriers between the construction area and the kitchen, and the door between these areas remained open during meal preparation. Opened and undated food was found in a kitchenette freezer, and a CNA assisted multiple residents with meal service and feeding without performing hand hygiene. Staff interviews confirmed expectations for hand hygiene and proper food storage were not met, and facility policy requirements for sanitation and cross-contamination prevention were not followed.
Five CNAs employed for over a year did not complete the required 12 hours of annual in-service education, as confirmed by a review of training records and staff interview. The responsible administrative nurse acknowledged oversight of this requirement, and facility policy specified the training should be based on employment date.
The facility did not ensure individualized activities programming based on resident preferences during weekends, offering only limited options like coloring, puzzles, and movies. Resident Council and staff reported inconsistent and infrequent staff-led activities on weekends, with no designated staff assigned to lead them. The facility could not provide a policy on activities, and residents experienced slow weekends with minimal engagement.
Narcotic count sheets for several medication carts and rooms showed repeated missing signatures from both oncoming and off-going nursing staff, indicating that required shift-to-shift controlled substance counts were not consistently performed or documented. Staff interviews confirmed that nurses and CMAs were expected to count together at each shift change, but this was not reliably done, resulting in a failure to follow facility policy for controlled medication accountability.
Staff did not date vials of tuberculin test serum after opening, as observed in the medication room refrigerator. Nursing staff confirmed the vials were opened and undated, and were unsure of the appropriate duration for use after opening. This was not in accordance with the facility's medication storage policy, which requires proper labeling and dating of medications.
Surveyors found that linen carts were left uncovered, washcloths were stored in handrails outside rooms, and respiratory equipment such as nebulizer masks and oxygen cannulas were not stored in sanitary, labeled bags as required. Nursing staff confirmed these practices did not follow facility policy, and the facility lacked policies for proper linen and washcloth storage.
Staff assisted two residents with eating by standing over them throughout meal service, rather than sitting at their level as required by facility policy and staff expectations. Interviews with multiple staff confirmed that the standard practice is to sit next to residents during meal assistance to maintain dignity.
A resident with significant physical and cognitive impairments was transported in a wheelchair without foot pedals by both a nurse and a CNA, despite her care plan and facility policy requiring assistive devices for safety. Staff interviews indicated that some residents' preferences were considered, but the lack of foot pedals was not care planned for this resident.
A resident with severe cognitive impairment and multiple diagnoses was admitted to hospice services, as documented in the EMR and physician orders. However, the MDS assessment did not reflect the resident's hospice status, and the care plan only referenced consulting hospice for pain management. The MDS nurse, working remotely, was not notified in a timely manner, leading to incomplete documentation and a deficiency in the assessment process.
A resident with multiple medical and cognitive impairments, dependent on staff for ADLs, was repeatedly observed with matted hair, food-stained clothing, and an unshaven face. Despite care plans and facility policy requiring staff assistance with grooming and hygiene, staff did not provide the necessary care or document any refusals, resulting in a deficiency related to grooming and personal hygiene.
A resident with CHF and multiple comorbidities did not have weekly weights recorded as ordered by the physician to monitor for fluid overload. Staff interviews revealed inconsistent communication and lack of physician notification when weights were missed, and documentation did not show any resident refusal or physician notification regarding the missed weights.
Multiple residents with severe cognitive impairment and fall risk did not have required fall prevention interventions in place, such as perimeter mattresses, Dycem mats, foot pedals on wheelchairs, and accessible call lights. Staff interviews confirmed expectations for these interventions, but observations showed they were not consistently implemented, contrary to care plans and facility policy.
A resident with COPD and other medical conditions had their nebulizer mask and nasal cannula left exposed on a bedside table and oxygen tank handle, rather than being stored in a clean, labeled bag as required by facility policy. Staff interviews and documentation confirmed that respiratory equipment should be stored in a sanitary manner, but this was not followed, resulting in a deficiency.
A resident with severe dementia and multiple comorbidities was not consistently supervised or redirected, resulting in repeated incidents of wandering, attempts to exit secured areas, and entering other residents' rooms. Staff did not follow the care plan interventions for supervision and redirection, and the facility could not provide a dementia care policy when requested.
A resident with multiple complex medical conditions who was receiving hospice care did not have a coordinated plan of care that integrated services provided by both the facility and hospice. Staff interviews revealed uncertainty about hospice-provided services and a lack of documentation in the care plan regarding hospice involvement, supplies, and schedules, despite facility policy requiring such coordination.
A communication breakdown led to a failure in administering physician-ordered medications to 19 residents during a scheduled medication pass. The incident involved a misunderstanding between an administrative nurse and a CMA, resulting in several residents missing critical medications for conditions such as hypertension, asthma, and Alzheimer's disease.
A communication breakdown led to ten residents not receiving their prescribed psychotropic medications during a scheduled evening medication pass. The incident involved a misunderstanding between a CMA and an administrative nurse, resulting in several medications, including antidepressants and antipsychotics, being missed. The facility's policy required medications to be administered as ordered, but this was not adhered to due to the oversight.
Failure to Implement and Document Diet Changes After Swallow Study and SLP Recommendations
Penalty
Summary
The deficiency involves the facility’s failure to act on speech therapy and swallow study recommendations for a resident with dysphagia and multiple neurologic and cognitive impairments. The resident had diagnoses including cerebral infarction, late-onset Alzheimer’s disease, generalized muscle weakness, dementia, and dysphagia. The admission MDS and associated CAAs documented that the resident required partial to moderate assistance with eating and other ADLs, had poor but improving appetite, and was on a CCHO/LCS diet with regular texture and consistency. The care plan identified risks for weight loss, swallowing and chewing problems, and directed staff to monitor intake, assure correct diet consistency for safe swallowing, and obtain speech therapy if chewing or swallowing problems were observed. Speech therapy notes documented that the resident had an episode of significant coughing and difficulty swallowing meat, after which nursing reportedly downgraded the diet to mechanical soft. On the following day, a FEES study was completed, which recommended a minced and moist mechanical soft diet with thin liquids, medications whole or cut in puree, and specific swallow strategies including maintaining upright positioning during and after meals and using a double swallow with every bite and drink. A subsequent speech therapy note recorded that the resident’s diet was mechanical soft with thin liquids and pills crushed in puree, and that the resident required total supervision at meals for safety. However, the EMR showed only a physician’s order for a CCHO/LCS diet with regular texture and consistency from admission through early February, with no documented diet changes or new diet orders reflecting the FEES recommendations. The swallow study report was uploaded into the resident’s EMR under the Misc tab by a licensed nurse, but the record lacked evidence that the provider was formally notified of the results or that any physician response was documented. Interviews with administrative and nursing staff revealed uncertainty about what happened with the swallow study and speech therapy recommendations, and staff described a process in which results were scanned into the EMR but might not generate alerts for review. The nurse who uploaded the swallow study stated she contacted the provider by phone, was told to continue the regular diet without changes, and did not document this contact or the provider’s response in a progress note. She also indicated she was unsure whether the provider had seen the speech therapy notes or recommendations. No relevant facility policy regarding handling orders and recommendations was provided upon request, and the EMR contained no evidence of diet order changes or documented physician rationale related to the swallow study and speech therapy recommendations during the resident’s stay.
Missed Yearly Performance Evaluation for CNA
Penalty
Summary
The facility failed to complete a required yearly performance evaluation for one of five Certified Nurse Aides (CNA) reviewed, specifically for a CNA who had been employed for over 12 months. Record review showed that this CNA, hired on 03/06/23, did not have a yearly performance evaluation available upon request. During an interview, the administrative nurse responsible for conducting these evaluations confirmed that the review had not been completed for the CNA, who worked night shifts. The facility's policy requires yearly performance evaluations to identify training needs and ensure compliance with state and federal regulations, but this process was not followed for the identified CNA. This deficiency was identified during a review of personnel records and staff interviews, with no mention of corrective actions or follow-up steps taken at the time of the report.
Lack of Full-Time Certified Dietary Manager
Penalty
Summary
The facility failed to employ a full-time certified dietary manager to oversee food and nutrition services for its 47 residents. Administrative staff confirmed that there was no certified dietary manager currently employed, and dietary staff reported that while she had been with the facility for over a year, she was not certified and had not yet started classes to obtain certification. The dietary manager only visited the facility monthly. The facility's own policy required a qualified, competent, and skilled dietary manager to help oversee food and nutrition services, but this standard was not met, resulting in a lack of proper oversight for the ordering, preparation, and storage of food for all residents.
Failure to Maintain Sanitary Food Service and Storage Standards
Penalty
Summary
Surveyors observed multiple failures to maintain sanitary dietary standards in the facility. During a walkthrough, the dining room was found closed to residents due to ongoing construction after a roof collapse, with ceiling fixtures hanging and dust covering tables and floors. There were no barriers separating the construction area from the kitchen, and the door between the dining room and kitchen remained propped open during meal preparation for all meals on the day of inspection. Additionally, opened and undated ice cream was found in the Memory Care Unit's kitchenette freezer. Staff interviews confirmed that the dining room was off-limits due to the roof issue and that there was an expectation for staff to clean and check refrigerators outside the kitchen area. Further observations revealed that a CNA assisted multiple residents with meal service and feeding without performing hand hygiene at any point during the breakfast service. Staff interviews indicated that hand hygiene was expected between assisting different residents and after touching soiled surfaces, but this was not followed. Dietary staff also stated that plastic barriers should have been in place to prevent contamination from the construction area if doors were open. Review of facility policy confirmed requirements for proper cleaning, labeling, dating, and storage of food, as well as hand hygiene and prevention of cross-contamination, all of which were not adhered to during the survey period.
Failure to Provide Required Annual In-Service Training for CNAs
Penalty
Summary
The facility failed to ensure that five Certified Nurse Aides (CNAs), each employed for more than 12 months, completed the required 12 hours of in-service education within the past 12 months, as verified through a review of in-service records. The CNAs identified had not met the annual in-service training requirement based on their employment dates, as specified in the facility's policy. The Administrative Nurse confirmed responsibility for ensuring direct care staff received the required training, but the records showed that none of the sampled CNAs had completed the necessary in-service hours during the review period.
Failure to Provide Individualized Activities Programming on Weekends
Penalty
Summary
The facility failed to develop and implement individualized activities programming based on resident preferences for weekends. Review of activity calendars for three months showed that only a limited selection of activities, such as church services, coloring, puzzles, and movies, were provided on weekends. Resident Council members reported that weekend activities were inconsistent compared to weekdays, with a lack of staff-led activities and reliance on passive options like television, coloring pages, and puzzles. Staff interviews confirmed that there was no designated staff member assigned to lead activities on weekends, and that the Activities Coordinator was responsible for planning but not for ensuring implementation. Unit staff were expected to provide activities, but this was not consistently done. The facility was unable to provide a policy related to activities when requested. The lack of individualized and staff-led activities on weekends placed residents at risk for decreased psychosocial well-being, boredom, and isolation, as directly reported by the Resident Council. The sample included 12 residents out of a census of 47, and the findings were based on observation, record review, and interviews with residents and staff.
Failure to Reconcile and Account for Controlled Substances Between Shifts
Penalty
Summary
The facility failed to ensure that controlled substances were properly accounted for and reconciled between shifts. Review of narcotic count sheets for multiple halls over several months revealed numerous missing signatures from both oncoming and off-going nursing staff, indicating that required shift-to-shift narcotic counts were not consistently performed or documented. Staff interviews confirmed that the facility's policy required nurses or Certified Medication Aides (CMAs) to count controlled substances together at each shift change, and that staff were not to leave until the count was correct. However, the documentation showed repeated lapses in this process. The facility's own policy required all narcotics to be stored securely and for any discrepancies to be reported immediately, with staff not leaving the area until discrepancies were resolved or reported. Despite these requirements, the observed missing signatures and lack of reconciliation demonstrated that the facility did not consistently follow its own procedures for controlled medication accountability. This failure was identified through direct observation, record review, and staff interviews, and affected the facility's ability to ensure the security and proper management of controlled substances for its residents.
Failure to Date Opened Tuberculin Test Serum Vials
Penalty
Summary
Staff failed to appropriately store medications and biologicals by not dating vials of tuberculin test serum after they were opened. During an observation of the medication room refrigerator, two vials of opened tuberculin test serum were found to be undated. Licensed nursing staff confirmed that the vials were opened and undated, and were unsure of the duration for which the serum remained usable after opening. Administrative nursing staff also stated that the vials should be dated with either an open date or an expiration date upon opening. The facility's Medication Storage policy required that all medications requiring refrigeration be stored properly and that the pharmacy and medication room be routinely inspected for discontinued, outdated, defective, or deteriorated medications, including those with missing labels. Despite this policy, the opened vials of tuberculin test serum were not dated, which constituted a failure to follow established procedures for medication storage.
Infection Control Deficiencies in Linen and Respiratory Equipment Storage
Penalty
Summary
Surveyors observed multiple infection control deficiencies during their review of the facility. Washcloths were found placed in handrails outside residents' rooms on several halls, and a linen cart containing towels, washcloths, and bedding was left uncovered. Additionally, a resident's nebulizer mask was found lying directly on a bedside table, and an oxygen tank with a nasal cannula was stored on a stand at the foot of the bed, with the cannula wrapped around the handle. These items were not stored in a sanitary manner as required by facility policy. Interviews with nursing staff confirmed that all respiratory equipment not in use should be placed in appropriately labeled bags, and that linen carts should always be covered. Staff also stated that washcloths should not be stored on guardrails outside residents' rooms. The facility's policy on oxygen administration required delivery devices to be covered in plastic bags when not in use, but there was no policy provided for the storage of linens in carts or washcloths. These failures in infection prevention and control practices were identified as placing residents at risk for infectious diseases.
Failure to Maintain Dignity During Meal Assistance
Penalty
Summary
Staff failed to provide a dignified care environment for two residents during meal service. On two separate occasions, a CNA and another unidentified staff member assisted residents with eating by standing over them for the entirety of their meals, rather than sitting at the residents' level. Interviews with staff, including a CNA, a licensed nurse, and an administrative nurse, confirmed that facility policy and expectations require staff to sit next to residents while assisting with meals to promote dignity. The facility's Resident's Rights policy also specifies the importance of ensuring a care environment that promotes dignity, choice, and respect for all residents.
Failure to Provide Wheelchair Foot Pedals During Resident Transport
Penalty
Summary
Staff failed to provide wheelchair foot pedals for a resident with multiple medical conditions, including muscle weakness, unsteadiness on feet, and impaired upper extremities, while she was being pushed in the hallway. Observations showed that the resident was transported by both a licensed nurse and a certified nurse's aide without foot pedals attached to her wheelchair, and staff asked her to hold her feet up during transport. The resident's care plan and assessments indicated she required assistance with activities of daily living and mobility, and that staff were to ensure her safety, including the use of appropriate assistive devices. Interviews with staff revealed that some residents do not like having foot pedals on their wheelchairs, and that staff sometimes allow residents to go without them if they express a preference. However, the facility's policy requires the use of adequate assistive devices to prevent accidents. The failure to provide foot pedals while pushing the resident in her wheelchair was not care planned and was inconsistent with both the resident's care needs and facility policy.
Failure to Accurately Document Hospice Admission on MDS Assessment
Penalty
Summary
The facility failed to complete an accurate Minimum Data Set (MDS) assessment for a resident regarding her admission to hospice services. The resident, who had diagnoses of dementia, anxiety, and major depressive disorder, was documented as being dependent on staff for activities of daily living and had a severely impaired cognition score. Although the resident's electronic medical record and physician orders indicated she was admitted to hospice services, the Significant Change MDS assessment did not reflect this status during the observation period. The care plan referenced consulting hospice for pain management, but the MDS lacked documentation of hospice services being provided. Interviews revealed that the MDS nurse worked remotely and relied on facility staff to communicate changes such as hospice admissions. The administrative nurse confirmed that a modification to the MDS should have been completed to indicate the resident's hospice status. The facility's policy required a Significant Change in Status Assessment when a resident enrolls in hospice, but this was not accurately documented, resulting in a deficiency related to the assessment process.
Failure to Assist Resident with Grooming and Facial Shaving
Penalty
Summary
Staff failed to provide necessary assistance with grooming and facial shaving for a resident with multiple medical conditions, including anxiety, bipolar disorder, diabetes mellitus, sleep apnea, asthma, muscle weakness, cognitive communication deficit, hypertension, major depressive disorder, and dysphagia. The resident's medical records indicated severe impairment in upper extremities and dependence on staff for toileting, bathing, and grooming. Care plans and assessments documented the need for staff assistance with ADLs, including reminders for hygiene and offers of sponge baths, but there was no documentation of refusals for bathing or shaving. Observations revealed the resident was left with matted hair, food-stained clothing, and an unshaven face on multiple occasions. Interviews with CNAs and nursing staff confirmed that it was their responsibility to ensure residents were clean, groomed, and shaven, and that refusals should be documented. However, the resident's EMR lacked such documentation, and the facility's policy required maintenance of grooming and hygiene for residents unable to perform ADLs. The failure to assist the resident with grooming and facial shaving constituted a deficiency in care.
Failure to Follow Physician's Order for Weekly Weights in Resident with CHF
Penalty
Summary
The facility failed to follow a physician's order for weekly weights for a resident with multiple complex medical conditions, including congestive heart failure (CHF), diabetes mellitus, chronic obstructive pulmonary disease (COPD), anemia, obesity, hypoxia, and muscle weakness. The resident's care plan and physician orders specifically required weekly weights to monitor for fluid overload due to diuretic use. Review of the Medication Administration Record (MAR) over a 15-week period showed that weights were not recorded on several scheduled dates, and there was no documentation that the physician was notified of missed weights or that the resident refused to be weighed. Interviews with staff revealed that CNAs were informed by nurses about which residents needed to be weighed, and if a weight was missed, they would attempt to obtain it the following day. However, the licensed nurse interviewed stated that she would not notify the physician of missed or refused weights. The administrative nurse indicated that if a weight could not be obtained, the physician should be notified, but there was no evidence this occurred. The facility's policy required consistent provision of physician-ordered services, but this was not followed in the case of weekly weights for this resident.
Failure to Implement and Maintain Fall Prevention Interventions
Penalty
Summary
The facility failed to ensure a safe care environment for multiple residents by not consistently implementing individualized fall prevention interventions as outlined in their care plans. One resident with severe cognitive impairment, bilateral lower extremity impairment, and a history of falls was observed without a perimeter mattress, despite this being a documented intervention following a recent fall. Staff interviews confirmed that fall interventions were expected to be in place, but observations on multiple days showed the perimeter mattress was missing. Another resident, also with severe cognitive impairment and a history of repeated falls, was care planned to have a Dycem mat in her wheelchair to prevent slipping. Observations revealed that the Dycem mat was not present in her chair on multiple occasions. Staff acknowledged that the Dycem was sometimes not replaced after transfers, and there was uncertainty about whether it was still needed after a change to a different type of wheelchair. The care plan still included this intervention, and staff were expected to ensure all interventions were in place each shift. A third resident with dementia, muscle weakness, and a history of falls was observed with her call light out of reach and being pushed in a wheelchair without foot pedals, contrary to her care plan interventions. Staff interviews confirmed that foot pedals should be used when pushing residents who cannot lift their feet and that call lights should always be within reach. The facility's own policies required individualized interventions to be implemented correctly and consistently, but these were not followed, placing residents at risk for preventable accidents and injuries.
Failure to Store Respiratory Equipment in a Sanitary Manner
Penalty
Summary
Staff failed to store a resident's nebulizer mask and nasal cannula in a sanitary manner, as observed during a survey. The resident, who had multiple diagnoses including COPD, required supplemental oxygen and nebulizer treatments per physician orders. On observation, the nebulizer mask was found lying directly on the bedside table and the nasal cannula was wrapped around the handle of an oxygen tank at the foot of the bed, rather than being stored in a clean, labeled bag as required by facility policy and staff statements. The resident's care plan and physician orders specified the need for regular cleaning and proper storage of respiratory equipment, but lacked specific instructions for storing the nebulizer when not in use. Interviews with staff confirmed that respiratory equipment should be placed in a labeled bag when not in use, and the facility's policy required delivery devices to be covered in plastic bags. The failure to follow these procedures resulted in the equipment being left exposed, which was identified as a deficiency by surveyors.
Failure to Provide Dementia Care and Supervision
Penalty
Summary
The facility failed to provide appropriate dementia-related care services for a resident with severe cognitive impairment, as evidenced by multiple incidents of wandering, attempts to exit secured areas, and entering other residents' rooms without adequate staff intervention. The resident, who had diagnoses including dementia, anemia, thrombocytopenia, kidney disease, hypokalemia, hyperlipidemia, muscle weakness, difficulty walking, unsteadiness, lack of coordination, and major depressive disorder, was admitted to the memory care unit and identified as being at risk for elopement. The care plan specified the use of a Wander Guard bracelet and instructed staff to provide meaningful activities, directional cues, and redirection to prevent elopement behaviors. Despite these interventions being outlined, staff failed to consistently supervise and redirect the resident. On several occasions, the resident was observed wandering unsupervised, attempting to open exit doors, and entering another resident's room to go through personal belongings. Staff interviews confirmed expectations for close monitoring, supervision, and redirection of cognitively impaired residents, but these were not consistently implemented. Additionally, the facility was unable to provide a policy related to dementia care when requested.
Failure to Coordinate Hospice Services in Resident Care Plan
Penalty
Summary
The facility failed to ensure a coordinated plan of care was developed and available for a resident who was receiving hospice services. The resident had multiple diagnoses, including COPD, major depressive disorder, myocardial infarction, rhabdomyolysis, bipolar disorder, dysphagia, anxiety, muscle weakness, hypertension, unsteadiness of feet, and Parkinson's disease. The resident was cognitively intact and required significant assistance with activities of daily living. The care plan documented that the resident was admitted to hospice and outlined general interventions for symptom management and communication with hospice, but did not specify the coordination of care and services between the facility and hospice provider. Interviews with facility staff, including a CNA, a licensed nurse, and an administrative nurse, revealed uncertainty and lack of clarity regarding what hospice provided for the resident, when hospice staff would be present, and what supplies or equipment were available. Staff indicated that this information was not included in the facility's care plan and relied on verbal communication from hospice staff. The facility's policy required coordination and documentation of care and services between the facility and hospice, but this was not reflected in the resident's care plan, resulting in a lack of a coordinated plan of care for the resident.
Medication Administration Failure
Penalty
Summary
The facility failed to ensure that 19 residents received their physician-ordered medications during the scheduled medication pass on the evening of April 8, 2024. This incident involved a misunderstanding between Administrative Nurse D and Certified Medication Aide (CMA) R, where Nurse D believed that CMA R had administered medications to all but one resident. However, it was later discovered that several residents had not received their medications as scheduled. The incident summary revealed that on the following day, CMA S contacted Administrative Nurse D to inquire about the previous evening's medication administration, leading to the discovery that many residents had missed their medications. The medications not administered included a range of critical drugs such as blood thinners, pain relievers, cholesterol-lowering medications, and treatments for conditions like Alzheimer's disease, asthma, and hypertension. The failure to administer these medications was attributed to a communication breakdown and a lack of oversight in ensuring that all medications were passed before the CMA left her shift. The facility's policy on medication administration, dated 2024, required that medications be administered as ordered by the physician and that staff review the Medication Administration Record to identify medications to be administered. Despite this policy, the facility did not ensure that the residents received their prescribed medications during the specified time frame, resulting in a significant medication error affecting multiple residents.
Medication Administration Failure
Penalty
Summary
The facility failed to ensure that ten residents received their physician-ordered psychotropic medications during the scheduled medication pass on the evening of April 8, 2024. The incident occurred when Certified Medication Aide (CMA) R left her shift, and Administrative Nurse D misunderstood her statement, believing that all medications had been administered except for one resident. However, it was later discovered that several residents had not received their medications. The medications missed included various antidepressants, antipsychotics, and antianxiety medications, which were crucial for the residents' treatment plans. The incident summary revealed that Administrative Nurse D was informed by CMA S the following day that several residents had not received their medications. Upon investigation, it was found that CMA R had only administered a handful of medications during the evening pass. The facility's policy on medication administration required that medications be administered as ordered by the physician, and staff were expected to review the Medication Administration Record to ensure compliance. The failure to administer the medications as scheduled was attributed to a communication breakdown and lack of verification by the night shift charge nurse.
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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