Below average — CMS composite of the measures below.
The next survey window likely opens around July 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Shawnee Gardens Healthcare & Rehab Center during CMS and state inspections, most recent first.
Unsanitary Food Preparation and Storage Conditions: Surveyors observed multiple sanitation issues in the kitchen and two kitchenettes, including a food prep cart with melted areas, debris on a refrigerator rack, rust on a rack holding clean pots and pans, wet meal trays put away, uncovered dry rice and oatmeal containers, and microwaves with dried food buildup on all inside surfaces. Dietary Staff BB confirmed the conditions, and the facility policy required sanitation of dining areas according to a written schedule.
Improper Garbage and Refuse Disposal: A dumpster lid was observed open with trash littering the ground around it, and later 14 bags of dietary and nursing trash were found stacked on the ground next to empty dumpsters instead of being placed inside. An admin staff member confirmed the bags had not been put into the dumpsters after the scheduled pickup was missed.
Infection Preventionist Lacked Required Certification Documentation: The facility failed to ensure the designated IP was certified and had completed the required specialized infection prevention training. An Administrative Nurse was unable to provide evidence of the IP's certification and stated the IP had taken over the role in December 2025, had earned certification at another facility, and did not have a copy of it. The facility policy required the IP to have specialized certification before assuming the role and to provide documentation of completion.
Unsafe and Dirty ERU Lounge Area: The ERU lounge area had repeated observations of trash, dirty cups, food debris, paper towels, an empty medicine cup, an unfolded gait belt, and a visibly dirty ice machine and counter. Staff gave inconsistent responses about who was responsible for cleaning the area, with a CNA unsure, an LN stating staff were to pick up trash and dishes, and an Administrative Nurse stating a contractor cleaned the ice machine semiannually.
Unsecured disinfectant chemicals were found in an unlocked cabinet over the dining counter in the Memory Unit, including an unmarked bottle with brown liquid, rapid cleaner disinfectant, and peri care wash. Staff stated chemicals should be locked in a cabinet or behind a locked door, and the facility policy required the environment to remain free of accident hazards. The unit housed 10 cognitively impaired, independently mobile residents.
Incomplete MDS CAAs for Two Residents: The facility failed to complete triggered CAAs for two residents. One resident’s Activity CAA and another resident’s Nutritional Status CAA were triggered on Significant Change MDS assessments but lacked an analysis of findings. An ADON confirmed the missing analysis, and an RN stated triggered CAAs were expected to include analysis.
The facility failed to accurately complete the MDS for two residents. One resident was coded as discharged to Home/Community with return anticipated, but the EMR showed the resident was admitted to the hospital. Another resident’s Significant Change MDS did not document CPAP use during the observation period, even though orders showed NIV/iVAPS-AE settings and an administrative nurse stated the CPAP should have been marked yes.
Failure to provide adequate ADL and hygiene assistance for a resident with severe physical and cognitive impairments. The resident was dependent on staff for bathing and other ADLs, yet was observed with greasy, debris-filled hair, debris in his beard and around his mouth, dried food on his shirt, and wet pants in the groin area. The resident said he had only had one shower since admission and had to give himself bed baths, while staff reported he mostly received bed baths and only showered occasionally.
Failure to provide ongoing activities for two residents with dementia and severe cognitive impairment. Both residents had documented preferences for music, animals, outdoor time, family visits, and other favorite activities, yet they were repeatedly observed sitting in wheelchairs at the dining table with no activity or stimulation. Staff stated the residents did not participate because of their cognition, while the Activity staff noted there were multiple activities available for residents with cognitive loss.
A resident with dementia, severe cognitive impairment, limited ROM in both LEs, and dependence on staff for wheelchair locomotion was observed sitting in her wheelchair with her feet hovering above the footrests. CNAs confirmed her feet did not reach the footrests, and an administrative nurse stated the footrest needed to be adjusted to better fit and support her feet.
Improper Storage of CPAP Mask and Oxygen Tubing: A resident with COPD, DM, dialysis dependence, and continuous O2 orders had his CPAP/NIV mask observed lying on the bedside table and his O2 tubing wrapped under the concentrator handle instead of being stored in a sanitary container or bag. Staff interviews confirmed the equipment should be stored in a bag when not in use, but it was not being kept that way during observation.
Incomplete Post-Dialysis Assessment Documentation: A resident with DM, COPD, and dependence on dialysis had repeated missing post-HD assessments on the dialysis communication sheet. The care plan and MD orders included dialysis attendance, AV fistula/graft monitoring, and pre-dialysis weights, but staff stated the resident was to be assessed after returning from dialysis and documented on the communication sheet; however, post-dialysis documentation was absent on many dialysis dates.
Failure to Document Hospice Collaboration in Care Plan: A resident with dementia, cognitive communication deficit, and myasthenia gravis was receiving hospice services, but the care plan did not include the frequency of hospice visits, the care hospice would provide, or the medications and equipment hospice would supply. Staff stated hospice-related information should be listed on the care plan, and the facility policy called for coordination of care with hospice staff.
Failure to Post Actual Nurse Staffing Hours: The facility posted nurse staffing sheets that listed staff counts and scheduled hours, but not the actual hours worked. Administrative staff stated the actual hours were recorded on a signed log kept in a lobby binder, but that log was not posted. The facility policy required nurse staffing information to be readily available and posted in a prominent, readable location.
The facility failed to report an allegation of abuse to the State Agency after a CMA observed an interaction between two cognitively impaired residents, including one resident being found in another resident’s room with his pants down. The CMA notified an LN, who contacted administrative staff, and an internal investigation was conducted, including interviews with both residents and review of video showing one resident in the other’s room for over a minute before staff intervened. Despite being informed of an incident described as inappropriate touching and having a policy requiring all alleged abuse to be reported, facility leadership, in consultation with corporate, decided not to report the allegation, concluding they could not determine willful intent and that the residents could make decisions about the interaction.
A resident with severe cognitive impairment and a history of stroke was denied visits from her family after the facility issued a trespassing order against her family member due to confrontational behavior and alleged verbal threats toward staff and the resident. The resident, who relied on family visits for social support, became visibly upset and expressed distress over the loss of visitation, while staff and the resident's representative confirmed no physical harm had occurred. The facility did not consult the LTC Ombudsman before restricting visitation, contrary to its policy on resident rights.
A resident with multiple comorbidities and a history of falls experienced a significant change in condition after staff failed to obtain physician-ordered urinalysis and laboratory tests. There was no documentation of attempts to collect the samples, resident refusals, or physician notification regarding the delays. The resident was later hospitalized with septic syndrome and urosepsis, and the facility could not provide the required lab results.
A cognitively impaired resident was sexually abused by another resident with a history of inappropriate sexual behaviors. The facility failed to implement preventative measures and adequately monitor the resident, leading to the incident. The victim did not consent to the touching, resulting in immediate jeopardy and fear.
A facility failed to implement effective preventative interventions for a resident with a history of sexual behaviors, placing female residents at risk. The resident's care plan lacked specific interventions for his behaviors, and incidents of inappropriate touching were not consistently documented or monitored. Staff interviews revealed inconsistencies in monitoring and reporting procedures, despite the facility's policy emphasizing resident safety and dignity.
A facility failed to effectively monitor and intervene in the behavioral health care of a resident with a history of sexual behaviors. Despite having a care plan, it lacked specific strategies and supervision requirements, leading to repeated inappropriate incidents with female residents. Staff interviews revealed inconsistencies in care plan execution, highlighting a deficiency in providing necessary behavioral health services.
The facility did not conduct a thorough assessment to determine necessary resources for competent care during routine and emergency situations. The assessment lacked details on resident capacity, input from residents, specific staffing needs, and required nursing competencies, putting all 115 residents at risk.
A facility with 115 residents failed to ensure agency staff received necessary communication training, risking impaired care and decreased quality of life. The facility could not provide training records for agency staff, including LNs and CNAs, as required by their policy. This oversight was identified during a review, highlighting a lapse in maintaining adequate training documentation.
A facility with 115 residents failed to ensure agency staff received required resident rights training, risking impaired care and decreased quality of life. The facility could not provide proof of training records for agency staff, including LNs and CNAs, during a review. Despite the facility's policy requiring sufficient staffing with appropriate training, the necessary records were unavailable, compromising resident safety and care quality.
The facility failed to ensure that agency staff received the required infection control training, as part of its infection prevention and control program. The facility could not provide proof of training records for agency staff, including an LN and a CNA. Administrative Nurse D stated that training records were typically reviewed online or communicated over the phone, but the facility was unable to provide the required records. This failure placed residents at risk for impaired care and decreased quality of life.
The facility failed to maintain resident dignity during meal assistance and personal care. Staff stood over two residents while feeding them, delayed addressing an incontinent accident in the dining room, and left a resident exposed during personal care. In the Memory Unit, a staff member made a derogatory comment about a resident's eating habits, leading to the resident refusing to eat. Additionally, staff referred to a resident as a "feeder" in a loud manner, violating the facility's dignity policy.
The facility failed to accommodate dietary preferences in the Memory Care Unit, with residents expressing dissatisfaction over limited breakfast options. Requests for specific items like pancakes, toast, and different cereals were denied, and coffee availability was delayed. Staff interviews revealed inconsistencies in food and beverage availability, contradicting the facility's policy to assess and accommodate residents' dietary needs and preferences.
The facility failed to implement effective infection control measures, including the absence of signage for Enhanced Barrier Precautions (EBP) and inadequate sanitation of shared equipment. Residents with medical conditions such as gastrostomy tubes and open wounds lacked protective equipment and signage. Additionally, staff did not perform proper hand hygiene, and trash was improperly stored, contributing to an unsanitary environment.
A resident with multiple medical conditions and impaired cognition was found to have their call light out of reach on two occasions, leaving them vulnerable to unmet care needs. Facility staff confirmed that call lights should be within reach, but this was not ensured, resulting in a deficiency.
A resident's care plan was not updated to reflect the discontinuation of a Foley catheter, leaving outdated instructions regarding toileting needs. Despite the resident's ability to manage toileting independently, the care plan continued to reference the catheter. Staff interviews confirmed the oversight, highlighting the need for regular updates to care plans to ensure accurate care instructions.
A resident with severe cognitive impairment and language barriers did not receive adequate communication support, leading to multiple incidents of confusion and distress. Despite care plan instructions to use translation services, staff failed to implement these strategies, resulting in the resident's inability to communicate effectively and causing disturbances in the Memory Care Unit.
The facility failed to provide adequate ADL assistance for several residents, including toileting and eating. A resident with quadriplegia was left with urine leaking onto the floor, another with severe cognitive impairment was not checked for incontinence for over four hours, and a third resident was unable to eat due to lack of staff assistance. These deficiencies highlight a failure to adhere to care plans and provide necessary support.
A resident with multiple sclerosis and a history of pressure ulcers had their low air-loss mattress set incorrectly at 220 lbs instead of their actual weight of 137 lbs. The facility's staff failed to ensure the mattress was set according to the resident's weight, as required by the care plan and facility policy, placing the resident at risk for skin breakdown.
A facility failed to implement fall prevention measures for two residents. One resident's wheelchair lacked an anti-rollback device, despite being at risk for falls due to severe cognitive impairment and limited mobility. Another resident's bed was left in a high position, posing a fall risk, despite her dependence on staff for mobility. Staff were unsure about the implementation of these safety measures, indicating a lapse in following care plans.
A facility failed to consistently communicate a resident's medical condition with the dialysis center, leading to a deficiency in dialysis care. The resident, with multiple medical conditions, required hemodialysis three times a week. The facility's records lacked evidence of necessary pre- and post-dialysis assessments on several dates, despite expectations for nursing staff to complete and return communication sheets. This failure placed the resident at risk of potential adverse outcomes related to dialysis.
A facility failed to provide appropriate dementia-related care for a resident with severe cognitive impairment, leading to inadequate communication and supervision. The resident, who required an interpreter, was not effectively redirected during incidents of confusion and wandering. Staff did not use translation services, resulting in unmanaged interactions with other residents. This deficiency risked the resident's quality of life and dignity.
The facility failed to ensure controlled substances were reconciled between shifts, with missing signatures on Narcotic Hand Off Count Sheets for multiple dates. Staff interviews confirmed that narcotics should be counted and documented at each shift change, as per facility policy. This failure placed residents at risk for medication misappropriation and diversion.
The facility failed to ensure a CP identified and reported missing dosage and application location for a resident's medication, placing them at risk for side effects. Additionally, the facility did not ensure CP recommendations for another resident were reviewed by the physician, risking unnecessary medication use. Staff interviews revealed a lack of clarity and action regarding pharmacy recommendations.
A resident with quadriplegia and dementia was at risk due to a deficiency in medication administration. The facility failed to ensure the resident's diclofenac order included a specific dosage and application area, leading to potential unnecessary medication use. The resident required significant assistance and had severely impaired cognition, and the facility could not provide a policy on physician's orders.
The facility failed to ensure proper collaboration and communication with hospice services for two residents receiving end-of-life care. For one resident, the care plan lacked documentation of medications, personal care items, and hospice visit frequency. Another resident's care plan did not specify hospice services such as medication and equipment. Both residents had complex medical histories, and the lack of coordination created a risk of missed or delayed services.
The facility failed to obtain informed declinations for the PCV20 vaccine for two residents, whose records showed refusals without documented informed declinations. This oversight was identified during a review of the facility's immunization practices, which require a signed consent form to be placed in the resident's permanent medical record.
The facility did not comply with the requirement to post daily staffing information, including the census, and maintain these records for 18 months. Inspections revealed missing census information on posted staffing sheets and multiple missing records over several months. An administrative nurse confirmed the requirement, but the facility lacked a related policy.
A cognitively impaired resident experienced multiple falls despite various interventions. The facility failed to provide adequate post-fall care, including neurological evaluations, after an unwitnessed fall that resulted in head trauma and fractures. Staff inconsistencies in following post-fall protocols were noted.
Unsanitary Food Preparation and Storage Conditions
Penalty
Summary
The facility failed to prepare and serve food under sanitary conditions in one kitchen and two kitchenettes. During an initial tour of the kitchen on 08/03/2026 at 07:42 AM, surveyors observed a three-tiered black plastic cart used for food preparation with two melted areas on the second tier, a black wire rack in the walk-in refrigerator with a build-up of food debris, a wire rack holding clean pots and pans with multiple areas of rust, 35 plastic trays used for serving residents' meals put away wet, a large plastic container of dry rice without a lid, and a plastic container of uncooked oatmeal left uncovered. During an initial tour of two kitchenettes on 08/03/2026 at 08:00 AM, the microwaves in both locations had a build-up of dried food on all inside surfaces. On 08/05/2026 at 07:56 AM, Dietary Staff BB confirmed the listed conditions. The facility policy, Sanitation of Dining and Food Service Areas, dated 2020, stated that Dining Services staff will uphold sanitation of the dining areas according to a thorough, written schedule.
Improper Garbage and Refuse Disposal
Penalty
Summary
Garbage and refuse were not disposed of properly when the facility failed to keep a dumpster lid closed and failed to place trash bags in an enclosure. During an initial kitchen tour on 08/03/2026 at 07:42, one of two dumpsters was observed with the cover open and random pieces of trash were littering the ground around the dumpster. On 08/05/2026 at 07:45 AM, both dumpsters were empty, but 14 bags of trash containing dietary and nursing trash were stacked next to one of the empty dumpsters instead of being placed inside it. At 07:56 AM, Administrative Staff A stated the sanitation company had not picked up the garbage on 08/04/2026 as planned but had picked it up in the early morning of 08/05/2026. Administrative Staff A confirmed the garbage bags had not been placed into the empty dumpsters and were stacked on the ground next to the dumpster. The facility policy stated garbage and rubbish would be disposed of to ensure a clean and sanitary kitchen that does not encourage insects or rodents, and that all outside dumpsters would be maintained in clean and sanitary condition.
Infection Preventionist Lacked Required Certification Documentation
Penalty
Summary
The facility failed to ensure the staff person designated as the Infection Preventionist (IP), who was responsible for the Infection Prevention and Control Program (IPCP), was certified and had completed the required specialized training in infection prevention and control. During record review on 08/04/2026 at 08:45 AM, Administrative Nurse D was unable to provide evidence of certification for the facility's IP. Later that morning, Administrative Nurse D stated she had taken over the IP position in December 2025, had obtained her IP certification at another facility, and did not have a copy of it, adding that she had been unable to obtain it. The facility policy stated the designated IP must have obtained specialized IP certification beyond initial professional training or education prior to assuming the role and must provide evidence of training through a certificate of completion or equivalent documentation.
Unsafe and Dirty ERU Lounge Area
Penalty
Summary
The facility failed to ensure a safe, clean, and homelike environment in the extended recovery unit (ERU) lounge area. During observation on 08/03/2026 at 07:47 AM, the lounge area across from the shower room and near the exit to the smoking area had three paper towels on the floor by the sink, the faucet was turned on, an empty medicine cup on the floor, an empty cup, an unfolded gait belt, and a clock with a loose battery on the table under the television. The area also had food debris on the floor next to a recliner, no trash bag in the trash can, a dirty cup upside down on the counter by the sink, visible substance on the ice machine, brown debris on the drain tray, two stacked plastic cups with a visibly dirty coffee cup beside the ice machine, and a visibly dirty counter under the ice machine with white debris. Additional observations on 08/03/2026 at 02:34 PM and 08/04/2026 at 07:55 AM showed continued clutter and dirt in the same lounge area, including dirty cups next to the ice dispenser machine, an empty medicine cup on the floor in front of the sink next to the trash can, a wrapper and piece of paper towel on the floor, and a dirty cup on the table under the television. On 08/05/2026, a CNA stated she did not know who was responsible for cleaning the ERU lounge area and ice machine, an LN stated a third-party contractor cleaned the ice machine and staff were to pick up trash and dishes, and an Administrative Nurse stated the contractor came semiannually and staff had been told to check the lounge area for trash and debris. The facility policy stated it would provide a safe, clean, comfortable, and homelike environment and allow residents to use personal belongings to the extent possible.
Unsecured disinfectant chemicals in Memory Unit
Penalty
Summary
The facility failed to ensure an environment free from accident hazards when staff left disinfectant chemicals unsecured in the Memory Unit. During an initial tour, surveyors observed an unlocked cabinet over the dining counter containing an unmarked bottle with brown liquid, a bottle of rapid cleaner disinfectant, and two small bottles of peri care wash. Staff interviews confirmed that chemicals should be locked: a CMA stated it was every staff member’s responsibility to ensure chemicals were in a locked cabinet, an LN stated chemicals should be locked in a cabinet or placed in the locked dirty laundry room, and an Administrative Nurse stated chemicals should be in a locked cabinet or behind a locked door and that all bottles should be labeled with contents. The facility’s Accidents and Supervision policy stated the resident environment would remain as free of accident hazards as possible and that each resident would receive adequate supervision and assistive devices to prevent accidents. The Memory Unit housed 10 cognitively impaired, independently mobile residents.
Incomplete MDS CAAs for Two Residents
Penalty
Summary
The facility failed to complete comprehensive MDS assessments for two residents. For R67, the EMR showed a Significant Change MDS dated [DATE], and the Activity CAA dated 06/05/26 was triggered but lacked an analysis of findings. For R10, the EMR showed a Significant Change MDS dated 05/01/2026, and the Nutritional Status CAA dated 05/06/2026 was triggered but also lacked an analysis of findings. On 08/05/26 at 11:15 AM, Administrative Nurse D confirmed that the Activity CAA for R67 was triggered but did not include an analysis of findings. On 08/04/26 at 11:30 AM, Administrative Nurse E stated that triggered CAAs were expected to include an analysis of findings and confirmed that the Nutritional Status CAA for R10 lacked analysis. The facility policy for MDS, revised 09/29/25, stated that residents are assessed using a comprehensive assessment process to identify care needs and develop an interdisciplinary care plan.
Inaccurate MDS Documentation for Discharge Location and CPAP Use
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) for two residents. For R118, the MDS dated [DATE] recorded discharge with return anticipated to Home/Community on 07/13/2026, but the EMR progress note for 07/13/2026 documented that R118 was admitted to the hospital. For R10, the Significant Change MDS dated 05/01/2026 did not document use of CPAP during the observation period, even though the EMR orders showed a non-invasive ventilator with iVAPS-AE settings, and Administrative Nurse E stated that R10's CPAP should have been marked yes because he used it in the facility. The facility policy for MDS stated residents are assessed using a comprehensive assessment process to identify care needs and develop an interdisciplinary care plan.
Failure to Provide Adequate ADL and Personal Hygiene Assistance
Penalty
Summary
The facility failed to provide necessary ADL assistance for a resident with significant physical and cognitive impairments, including subarachnoid hemorrhage, lack of coordination, contractures, quadriplegia, neuropathy, and dementia. The resident’s MDS documented dependence on staff for bathing and all other ADLs, and care planning directed staff to provide substantial assistance with oral hygiene, toileting hygiene, and bathing, including sponge bathing with washcloths and soapy water if bathing was refused. The resident’s record showed bathing was documented eight times over the review period, with three refusals noted in July 2026, but the documentation did not specify whether the care provided was a bath, shower, or bed bath. During observations, the resident was seen with uncombed, greasy hair containing debris, debris in his beard and around his mouth, dried food stains on his shirt, wet pants in the groin area, and later with hair that remained unkempt, matted, oily, and full of white debris. The resident stated he had only been allowed one shower since admission, had been told he would get a shower two weeks earlier but never did, and said he had to give himself bed baths. A CNA reported the resident did not go into the shower and received bed baths, while an LPN stated the resident only received a shower 25% of the time and a bed bath the other 75% of the time, and was unsure whether staff cleaned his hair well. An administrative nurse stated the resident was dependent on staff for mechanical-lift transfers and that shower caps should be used when bed baths were provided.
Failure to Provide Ongoing Activities for Residents With Dementia
Penalty
Summary
The facility failed to provide an ongoing program of activities designed to meet the interests and well-being of two residents with dementia and severe cognitive impairment. R11’s records showed preferences for listening to music, being around animals, spending time outdoors, and participating in favorite activities, and R67’s records showed preferences for listening to music, being around animals, spending time outdoors, visiting with family, going outdoors, and looking out the window. Both residents were dependent on staff for locomotion in wheelchairs, and both had care plans identifying activities they enjoyed or daily routines and activities they should have the opportunity to engage in. During observations on multiple occasions, both residents were seated in their wheelchairs at the dining table with peers while no activity or stimulation was occurring. Staff interviews indicated the residents did not participate in activities because they had dementia or cognitive loss and would sit and people watch. The Activity Staff stated there were multiple activities for residents with cognitive loss to do while seated at the dining room table and that staff education would be needed to ensure activities were brought out and used routinely. The Activity CAA for R67 triggered but lacked an analysis of findings, and the facility policy stated it was the policy to provide an ongoing program to support residents in their choice of activities.
Wheelchair Footrest Not Adjusted for Resident With Limited LE ROM
Penalty
Summary
The facility failed to ensure appropriate wheelchair positioning for R11. R11 had a diagnosis of dementia, severe cognitive impairment on MDS assessments, limited ROM in both lower extremities, and was dependent on staff for locomotion in her wheelchair. Her care plan, revised 07/02/2026, instructed staff that she was dependent on staff for locomotion in her wheelchair. During observations on 08/03/2026 and 08/04/2026, R11 was seen sitting in her wheelchair at the dining room table with her feet hovering several inches above the wheelchair footrest. CNA M confirmed on 08/04/2026 that R11's feet did not reach the footrests, and CNA N stated the footrest needed to be adjusted to fit R11 better. On 08/05/2026, Administrative Nurse D also stated the footrest needed to be adjusted to better fit the resident and support her feet. The facility policy for Use of Assistive Devices stated that assistive device use would be based on the resident's needs, as indicated.
Improper Storage of CPAP Mask and Oxygen Tubing
Penalty
Summary
The facility failed to ensure Resident 10’s CPAP/NIV mask and oxygen tubing were stored in a sanitary manner. Resident 10 had diagnoses including DM, COPD, dialysis dependence, and dependence on supplemental oxygen. His record included physician orders for NIV use at night with oxygen at 3 LPM connected to the device, and oxygen at 3 LPM via nasal cannula after the mask was removed in the morning. The resident’s MDS documented a BIMS score of 15, indicating intact cognition, and his care plan included staff assistance with respiratory equipment as ordered. During observation, the resident’s NIV mask was seen lying directly on the bedside table next to the machine rather than in a container. On another observation, the resident’s oxygen tubing was wrapped together and placed under the handle of the oxygen concentrator instead of being stored in a container. A CNA stated she would transfer the oxygen tubing from the concentrator to the portable oxygen tank after getting the resident up and then place the tubing inside the concentrator handle. An LN stated the CPAP mask and oxygen tubing should be stored in a bag when not in use, and an Administrative Nurse stated the respiratory equipment should be cleaned and changed as ordered and stored in the dated bag.
Incomplete Post-Dialysis Assessment Documentation
Penalty
Summary
Safe, appropriate dialysis care/services were not provided for a resident who required hemodialysis. The resident had diagnoses of DM, COPD, dependence on dialysis, and dependence on supplemental oxygen, and the MDS documented a BIMS score of 15 with dialysis received during the observation period. The care plan included interventions for dialysis attendance, shunt monitoring, blood pressure precautions for the shunt arm, and daily weights, but the dialysis-related documentation was incomplete. The physician orders included dialysis on Monday, Wednesday, and Friday, readiness for dialysis by 10:30 AM, monitoring of the AV fistula/graft site upon return from dialysis, and weighing before dialysis for fluid management. Review of the Dialysis Communication Form from 05/01/2026 through 08/03/2026 revealed 41 dialysis communication sheets, and post-dialysis documentation was missing on 25 dates. The facility’s staff stated the resident would be assessed upon return from dialysis and documented on the dialysis communication sheet, and administrative staff stated the charge nurse was expected to complete and document the post-return assessment. The facility’s Hemodialysis policy stated it would provide care and treatment consistent with professional standards of practice, physician orders, the comprehensive person-centered care plan, and the resident’s goals and preferences.
Failure to Document Hospice Collaboration in Care Plan
Penalty
Summary
The facility failed to ensure collaboration with the hospice provider for a resident with cognitive communication deficit, dementia, and myasthenia gravis. The resident’s EMR documented a diagnosis of myasthenia gravis, and the Quarterly MDS showed a BIMS score of 12, indicating moderately impaired cognition. The resident had received hospice services, and the care area assessment noted staff would assist with activities of daily living as needed and therapy would work to increase functional mobility. The resident’s care plan included interventions for pain, restlessness, agitation, constipation, and other symptoms of discomfort, along with instructions to notify hospice of significant changes, clinical complications, need for emergency transfer, or death. However, the plan did not include the frequency of hospice staff visits or the care they would provide, and it did not list the medications and equipment to be provided by hospice. Staff interviews indicated the hospice-related information should be included on the resident’s care plan, and the facility’s hospice coordination policy stated care would be coordinated with hospice staff to promote the resident’s highest practicable well-being.
Failure to Post Actual Nurse Staffing Hours
Penalty
Summary
The facility failed to post the required nurse staffing information because the staffing sheets posted from 02/02/2025 to 08/02/2026 did not list the actual hours worked by staff. Survey review found the posted sheets showed the number of staff and scheduled hours, but not the actual hours worked, and the facility was unable to provide posted staffing documentation containing all actual hours worked. During interviews, Administrative Staff A stated the staff coordinator completed the daily posting forms and that a posted staffing sheet had been created to meet state requirements. Administrative Staff A also stated that actual staff hours were available on a log requiring staff signatures, but that the log was kept in a binder in the lobby and was not posted. The facility policy stated nurse staffing information was to be readily available in a readable format and posted in a prominent place accessible to residents, staff, and visitors.
Failure to Report Resident-to-Resident Abuse Allegation to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of abuse between two cognitively impaired residents to the State Agency (SA) as required by policy. On 03/29/26, a CMA observed an interaction between two residents in which one resident was later alleged to have been in the other resident’s room with his pants down. The CMA reported this to an LN, who then contacted administrative staff. Administrative staff and a nurse initiated an internal inquiry, including entering the alleged victim’s room, where the resident was in bed and did not appear in distress. When questioned, the alleged victim denied concerns about visitors entering the room and stated she would tell an unwelcomed visitor to leave, and that she would not be offended by advances from a welcomed visitor. As part of the internal investigation, Social Services interviewed the alleged perpetrator, who had no recollection of any interaction with the other resident. The CMA later described that she had seen the alleged perpetrator rolling down the hallway, instructed him to return to his room, and then, upon passing near the alleged victim’s door, entered the room and immediately separated the two residents. The alleged victim yelled and questioned what the CMA was doing. Video surveillance showed that the alleged perpetrator entered the alleged victim’s room and remained there for one minute and 40 seconds before the CMA entered. The facility’s investigation narrative documented that Social Services assessed both residents for psychosocial well-being and determined neither was at risk from the allegation. During surveyor interviews, the LN stated she had been told by the CMA that she walked in on the resident in the other resident’s room with his pants down and that the alleged victim was just lying there. The LN reported she notified an administrative nurse, who directed her to call the administrator, and she did so. The administrator and administrative nurse both acknowledged they were informed of an incident of inappropriate touching between the two residents. They further stated that, after working with corporate and completing their investigation, they decided not to report the allegation to the SA because they believed the residents could make decisions about the interaction and could not define willful intent of abuse. This decision was made despite facility policy directing that all alleged violations involving abuse, neglect, exploitation, or mistreatment be reported to the SA within required time frames and that investigation results be reported within five working days.
Failure to Honor Resident Visitation Rights
Penalty
Summary
A resident with a history of cerebral infarction and severe cognitive impairment, as indicated by a BIMS score of three, was denied the right to receive visitors of her choosing at the time of her choosing. The resident's care plan allowed her to make daily decisions and emphasized maintaining a consistent routine to reduce confusion. Despite this, the facility issued a trespassing order against the resident's family member following an incident where the family member was reported to have been confrontational with staff and allegedly threatened to slap the resident. The family member denied threatening the resident but admitted to using profanity and confronting staff. The facility's investigation documented that staff intervened when the family member became verbally abusive and refused to leave, resulting in police involvement and the issuance of a trespassing order that barred the family member from visiting for one year. The resident expressed distress over the inability to see her family, stating that her family was her only visitor and that she never felt unsafe around them. The resident became visibly upset and cried when discussing the situation, indicating a negative impact on her psychosocial well-being. Interviews with staff and the resident's representative revealed that while the family member had issues controlling anger and was verbally abusive to staff, there was no evidence of physical violence toward the resident. The facility did not consult the Long-Term Care Ombudsman regarding the visitation restriction. The facility's policy states that residents have the right to receive visitors of their choosing, but this right was not upheld in this case, resulting in social isolation and emotional distress for the resident.
Failure to Obtain and Document Physician-Ordered Labs and Notify Physician of Delays
Penalty
Summary
The facility failed to obtain a physician-ordered urinalysis (UA) and other laboratory tests for a resident, despite orders being placed. The resident had a history of chronic kidney disease, recurrent UTIs, atrial fibrillation, repeated falls, and cognitive communication deficits. Orders for a UA, CBC, CMP, and magnesium were placed, but the medical record lacked documentation of any attempts to collect the samples or any refusals by the resident prior to a significant change in condition. There was also no evidence that the physician was notified of the inability to obtain the samples or of any refusals. The resident experienced multiple falls and a change in condition over several days, including confusion, disorientation, and eventually unresponsiveness with respiratory distress. Despite these changes, staff did not document attempts to obtain the ordered tests, nor did they notify the physician about the delays or the resident's refusals. Interviews with staff confirmed that while some claimed the resident refused the UA and labs, there was no documentation of these refusals or of physician notification in the medical record. The facility's own policies required timely notification of changes in condition and provision of physician-ordered services, but these were not followed. Ultimately, the resident was sent to the hospital in an unresponsive state with a high fever and was admitted to the ICU for septic syndrome, urosepsis, and other acute conditions. The lack of timely diagnostic testing and failure to notify the physician of the delays or refusals contributed to a delay in care. The facility was unable to provide any results for the ordered tests, and staff interviews revealed inconsistent practices and a lack of adherence to documentation and notification protocols.
Failure to Prevent Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to prevent an episode of resident-to-resident sexual abuse involving two cognitively impaired residents. On the specified date, staff witnessed one resident groping another resident's nipples, breast, and buttocks while both were seated at the dinner table on a locked unit for cognitively impaired residents. The victim voiced that she did not consent to the touching, placing her in immediate jeopardy and at risk for ongoing abuse and fear. The resident who committed the abuse had a history of sexual behaviors related to psychiatric illness, as noted in his medical records. Despite this, his care plan did not adequately address his sexual behaviors, and he was moved to a new unit without implementing preventative interventions. The resident's care plan included instructions for staff to explain and reinforce why his behaviors were inappropriate, but it failed to prevent the incident. Additionally, the facility's staff did not ensure close monitoring of the resident, which contributed to the occurrence of the abuse. The facility's policy on abuse, neglect, and exploitation was not effectively enforced, as evidenced by the failure to protect the victim from abuse. The facility did not identify and implement necessary preventative measures related to the resident's sexual behaviors upon his relocation to a new unit, placing other female residents at risk for similar incidents. This deficiency resulted in feelings of fear and potential psychosocial harm for the victim.
Removal Plan
- R1 was placed on one-on-one supervision until psychiatric evaluation can be completed.
- The facility identified all at-risk residents on the unit.
- Staff were provided in-service on abuse, neglect, and exploitation with comprehensive testing.
- Safe survey conducted on female residents of unit.
- Psychiatric evaluation will be completed.
Failure to Implement Preventative Interventions for Resident's Sexual Behaviors
Penalty
Summary
The facility failed to implement effective preventative interventions to manage a resident's sexual behaviors, which placed female residents at risk. The resident in question, identified as R1, had a history of sexual behaviors related to psychiatric illness, as noted in his medical records. Despite this, his care plan lacked specific interventions to address his sexual behaviors towards female residents, and there was insufficient supervision and monitoring when he was outside his room. The care plan did not include necessary precautions such as supervision around female residents or monitoring while he was out of his room. Multiple incidents were documented where R1 engaged in inappropriate sexual behaviors towards female residents. These incidents included inappropriate touching and physical aggression, which were not adequately addressed in his care plan or through staff supervision. For instance, R1 was observed touching a female resident inappropriately during meal service, and another incident involved him touching a female resident's arm despite her attempts to push him away. These behaviors were not consistently documented or monitored in his electronic medical records, indicating a lack of effective intervention and oversight. Interviews with staff revealed inconsistencies in the understanding and implementation of monitoring and reporting procedures for R1's behaviors. Staff members were aware of R1's history but did not consistently document or monitor his behaviors as required. The facility's policy on abuse, neglect, and exploitation emphasized the need for resident safety and dignity, yet the facility failed to protect female residents from R1's inappropriate behaviors. This deficiency placed R2 and 19 other female residents at risk, highlighting a significant lapse in the facility's duty to provide a safe environment.
Inadequate Behavioral Monitoring and Interventions for Resident
Penalty
Summary
The facility failed to implement effective behavioral monitoring and interventions for a resident with a history of sexual behaviors related to psychiatric illness. The resident, who had diagnoses including chronic obstructive pulmonary disease and depression, exhibited sexually inappropriate behaviors towards female residents. Despite having a care plan that noted these behaviors, the plan lacked specific triggers, coping strategies, and supervision requirements necessary to prevent such behaviors. The resident's electronic medical records and care plan did not adequately document or address these behaviors, leading to repeated incidents. Multiple incidents were documented where the resident engaged in inappropriate touching and aggressive behaviors towards female residents. These incidents were recorded in the resident's progress notes, but there was a lack of consistent monitoring and documentation in the electronic medical records, particularly in the Tasks and Treatment Administration Report sections. The facility's policy required ongoing behavioral monitoring and supervision for cognitively impaired residents, but this was not effectively implemented for the resident in question. Interviews with facility staff revealed inconsistencies in the understanding and execution of the care plan. Staff were aware of the resident's history and the need for monitoring, but the care plan did not clearly outline the necessary interventions and supervision. The facility's failure to provide adequate behavioral health care and services placed the resident at risk for continued behavioral episodes and unmet care needs.
Inadequate Facility-Wide Assessment
Penalty
Summary
The facility failed to conduct a comprehensive facility-wide assessment to determine the necessary resources for competent resident care during both routine operations and emergencies. The assessment, dated [DATE], did not specify the facility's resident capacity, nor did it include input from residents and their representatives. Additionally, it lacked details on the specific staffing needs for each unit based on the resident population and did not identify the competencies and skill sets required by nursing staff to adequately care for the residents. An administrative nurse mentioned that the assessment was recently revised, but the facility could not provide a policy related to the assessment when requested. This oversight placed all 115 residents at risk for inadequate care.
Failure to Provide Required Communication Training for Agency Staff
Penalty
Summary
The facility, with a census of 115 residents, failed to ensure that agency staff received the required communication training, which is essential for providing quality care. During a review on September 11, 2024, the facility could not provide proof of training records for agency staff, including Licensed Nurses K and L, and Certified Nurse's Aide OO. Administrative Nurse D mentioned that the facility typically reviews training records online or receives information over the phone about the training or classes completed by agency staff. However, the facility was unable to provide the requested training records by September 18, 2024. According to the facility's Nursing Services and Sufficient Staffing policy, revised in October 2022, the facility is responsible for ensuring sufficient staffing with appropriate training, competencies, and skill sets to assure resident safety and the highest level of resident care. The failure to complete the required communication training for staff providing care in the facility placed residents at risk for impaired care and decreased quality of life.
Failure to Provide Required Resident Rights Training for Agency Staff
Penalty
Summary
The facility, with a census of 115 residents, failed to ensure that agency staff received the required resident rights training, which is essential for providing proper care and maintaining the quality of life for residents. During a review on 09/11/24, the facility could not provide proof of training records for agency staff, including Licensed Nurses K and L, and Certified Nurse's Aide OO. Administrative Nurse D mentioned that the facility typically reviews training records online or receives information over the phone regarding the training or classes completed by agency staff. However, the facility was unable to provide the necessary training records when requested on 09/18/24. According to the facility's Nursing Services and Sufficient Staffing policy, revised in October 2022, the facility is required to provide sufficient staffing with appropriate training, competencies, and skill sets to ensure resident safety and achieve the highest level of resident care. The failure to complete the required resident rights training for staff who provided care in the facility placed residents at risk for impaired care and decreased quality of life.
Failure to Ensure Infection Control Training for Agency Staff
Penalty
Summary
The facility, with a census of 115 residents, failed to ensure that agency staff received the required infection control training, which is a part of its infection prevention and control program. During a review on 09/11/24, the facility was unable to provide proof of training records for agency staff, specifically for Licensed Nurse (LN) K, LN L, and Certified Nurse's Aide (CNA) OO. Administrative Nurse D mentioned that the facility would typically review records online or receive information over the phone regarding the training or classes completed by agency staff. However, the facility was unable to provide the required training records as requested on 09/18/24. The facility's Nursing Services and Sufficient Staffing policy, revised in 10/2022, indicated that the facility would provide sufficient staffing with appropriate training, competencies, and skill sets to ensure resident safety and achieve the highest level of resident care. The failure to ensure the completion of the required infection control training for staff who provided care in the facility placed the residents at risk for impaired care and decreased quality of life.
Failure to Maintain Resident Dignity During Care
Penalty
Summary
The facility failed to maintain the dignity of several residents during meal assistance and personal care. Two residents, R17 and R41, were observed being fed by staff who stood over them, which is against the facility's policy of sitting with residents during meals. Another resident, R92, experienced an incontinent accident in the dining room, and staff delayed in addressing the situation, leading to other residents noticing and commenting on the incident. Additionally, R35 was left exposed during personal care with the room door open, compromising privacy. In the Memory Unit, staff failed to treat R108 with respect during mealtime. Activity Z made a derogatory comment about R108's eating habits, which led to R108 refusing to eat and moving away from the table. Furthermore, staff referred to R35 as a "feeder" in a loud manner in the hallway, which is disrespectful and against the facility's dignity policy. Interviews with staff confirmed that these actions were not in line with the expected standards of care, which emphasize maintaining resident dignity and privacy.
Failure to Accommodate Dietary Preferences in Memory Care Unit
Penalty
Summary
The facility failed to accommodate the dietary preferences of its residents, particularly in the Memory Care Unit. Multiple residents expressed dissatisfaction with the lack of meal options, specifically during breakfast. One resident repeatedly requested pancakes and toast but was denied and given Cheerios instead. Another resident asked for a different type of cereal but was told only Cheerios were available. Additionally, residents were informed that seconds were not available, and coffee requests were delayed until the arrival of the breakfast cart. The Resident Council also reported that alternative meal options were not provided for breakfast, and pancakes were only served on Saturdays. Staff interviews revealed inconsistencies in the availability of food and beverages. A CNA mentioned that coffee was always available but required a call to the kitchen, and alternative menus were only offered for lunch and dinner. An administrative nurse stated that staff should communicate with the kitchen for additional items, and units should have drinks and snacks available. However, a dietary staff member indicated that alternatives for breakfast could not be provided, although pancakes, coffee, and cereal options were available upon request. The facility's Food Preferences policy stated that residents' dietary needs and preferences should be assessed and accommodated, but this was not effectively implemented, leading to the deficiency.
Inadequate Infection Control Measures
Penalty
Summary
The facility failed to implement an effective infection prevention and control program, as evidenced by several deficiencies observed during a survey. The facility did not provide appropriate signage or indicators to alert staff and visitors of residents on Enhanced Barrier Precautions (EBP), which are necessary to reduce the transmission of resistant organisms. Specifically, rooms of residents with medical conditions such as percutaneous endoscope gastrostomy tubes, open wounds, and suprapubic catheters lacked protective equipment and signage indicating EBP. Additionally, shared equipment like the Hoyer lift was not sanitized between uses, and staff did not perform adequate hand hygiene during resident care, as observed when a CNA failed to change soiled gloves before touching clean items. The facility also failed to maintain a sanitary environment, as evidenced by improper trash storage and uncleaned spills. Large trash bags containing soiled items were left on the floor across from the nurse's station, and a brown substance was found in a dining room cabinet. Administrative Nurse D confirmed that signs should be posted for residents requiring EBP, and staff should adhere to hand hygiene protocols. The facility's Infection Prevention and Control Program, dated 11/01/19, was not effectively implemented, placing residents at risk for infectious diseases.
Resident's Call Light Inaccessible
Penalty
Summary
The facility failed to ensure that a resident's call light was within reach, which left the resident vulnerable to unmet care needs. The resident, identified as R37, had multiple medical conditions including sleep apnea, diabetes mellitus, hypertension, congestive heart failure, bipolar disorder, depressive disorder, Parkinson's disease, chronic obstructive pulmonary disease, dysphagia, and end-stage renal disease. The resident was documented as having moderately impaired cognition and was dependent on staff for activities of daily living, including eating, showering, and personal hygiene. Observations on two separate occasions revealed that the resident's call light was on the floor, out of reach, while the resident was either in bed or in a wheelchair. Interviews with facility staff, including a licensed nurse, a certified nurse's aide, and an administrative nurse, confirmed that call lights should be within reach of residents at all times. The facility's policy on the accommodation of needs also stated that reasonable accommodations should be made for individual resident needs and preferences. Despite these guidelines, the facility did not ensure that the resident's call light was accessible, resulting in a deficiency in care.
Failure to Update Resident's Care Plan Post-Catheter Removal
Penalty
Summary
The facility failed to update the care plan of a resident, identified as R106, to reflect his current toileting needs after the discontinuation of his Foley catheter. R106 was admitted with a Foley catheter, which was removed shortly after admission. Despite this change, the care plan continued to indicate the presence of the catheter and did not provide updated instructions for his toileting needs. This oversight was identified during a review of the resident's care plan, which lacked necessary updates to reflect his ability to independently manage his toileting and personal hygiene. Observations and interviews with staff revealed that the care plan should have been updated to reflect the resident's current needs. A CNA and a licensed nurse both acknowledged that the care plan was outdated and should have been revised to remove references to the Foley catheter. The administrative nurse confirmed that care plans should be reviewed and updated regularly, including when there are changes in a resident's condition. The failure to update the care plan placed the resident at risk for impaired care due to uncommunicated care needs.
Failure to Utilize Translation Services for Non-English Speaking Resident
Penalty
Summary
The facility failed to ensure that a resident, identified as R99, received appropriate supportive care and services to maintain her quality of life. R99, who has severe cognitive impairment, dementia, general anxiety disorder, and a cognitive communication disorder, was not provided with adequate tools or strategies to communicate her needs, wants, or feelings. Despite her care plan indicating the need for an interpreter and the use of translation services, staff did not utilize these resources effectively, leading to multiple incidents where R99 was unable to understand or be understood by staff. On several occasions, R99 was observed wandering the Memory Care Unit and entering other residents' rooms, causing confusion and distress. Staff attempted to redirect her using English, which she did not understand, and failed to use available translation services or cue cards to communicate with her. This lack of communication led to incidents where R99 inadvertently disturbed other residents, such as attempting to assist another resident during lunch, which resulted in a verbal altercation. The facility's failure to implement the necessary communication strategies as outlined in R99's care plan placed her at risk for decreased quality of life, isolation, and impaired dignity. Despite having policies in place for communication with residents with limited English proficiency, staff did not consistently apply these measures, contributing to the deficiency identified in the report.
Deficiencies in ADL Assistance for Residents
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs) for several residents, leading to deficiencies in care. Resident 92, who had diagnoses of quadriplegia, dementia, and encephalopathy, was dependent on staff for all ADLs, including toileting. Despite being on a two-hour check schedule, Resident 92 was observed with urine leaking from his brief onto the dining room floor, indicating a failure to provide timely incontinence care. Staff interviews revealed that Resident 92 was not checked and changed as required, especially before meals, which was a directive in his care plan. Resident 68, who had severe cognitive impairment and was dependent on staff for all ADLs, was left without toileting or incontinence checks for over four hours while sitting in a Broda chair. This lack of attention to his toileting needs was contrary to his care plan, which required regular checks and changes to maintain dignity and prevent skin breakdown. Staff interviews confirmed that Resident 68 should have been checked every two hours and provided with bathroom opportunities after meals. Resident 37, with multiple diagnoses including sleep apnea, diabetes, and Parkinson's disease, was dependent on staff for eating and other ADLs. On one occasion, Resident 37 was left in bed with his breakfast tray out of reach, and he was unable to eat without assistance. Despite his request to be taken to the dining room, he was not assisted due to a lack of available staff. This resulted in Resident 37 being unable to consume his meal, as observed when his tray was removed with most of the food untouched. Staff interviews indicated that there should have been enough staff to assist with his needs, but this was not provided, leading to a deficiency in care.
Improper Setting of Low Air-Loss Mattress for Resident
Penalty
Summary
The facility failed to ensure that a resident's low air-loss (LAL) mattress pump was set correctly according to the resident's weight, which is crucial for pressure ulcer prevention and care. The resident, who had multiple sclerosis, heart failure, and a history of pressure ulcers, was dependent on staff for all functional abilities and was incontinent of both bladder and bowel function. The resident's care plan included the use of a LAL mattress to prevent skin breakdown, but the mattress was found to be set at 220 lbs, which was inappropriate for the resident's actual weight of 137 lbs. The deficiency was identified through observations, record reviews, and interviews. The resident's electronic medical record (EMR) and treatment administration record (TAR) documented the requirement for the LAL mattress to be checked every shift to ensure it was set correctly based on the resident's weight. However, the TAR lacked documentation of the resident's weight or the setting of the LAL machine. Interviews with staff revealed a lack of knowledge regarding the correct setting for the LAL mattress, with both a certified nurse aide and a licensed nurse unable to specify the appropriate setting. The facility's policy on the use of support surfaces required that such devices be utilized according to the manufacturer's recommendations and checked each shift for proper functioning. Despite this policy, the resident's LAL mattress was not set according to the physician's order or the resident's weight, placing the resident at risk for complications related to skin breakdown and pressure ulcers.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to implement the fall intervention of anti-rollback devices for a resident, identified as R41, as per his care plan. R41 had severe cognitive impairment and was dependent on staff assistance for various activities of daily living. Despite being at risk for falls due to his medical conditions and limited mobility, his wheelchair lacked the necessary anti-rollback device, which was observed during a survey. Staff members, including a CNA and a licensed nurse, were unsure if the device had ever been placed on the wheelchair, indicating a lapse in following the care plan. Another deficiency was noted when a resident, identified as R36, was found with her bed left in a high position, posing a risk for falls. R36 had severely impaired cognition and was dependent on staff for mobility and other daily activities. Observations showed that her bed was elevated three feet off the floor, and she was unable to lower it herself. Staff members, including a CNA and a licensed nurse, acknowledged that the bed should not have been left in such a position, highlighting a failure to ensure a safe environment. The facility's policies on accidents and supervision were not adequately followed, as evidenced by the lack of implementation of individualized interventions to minimize fall risks for both residents. The care plans for R41 and R36 were not effectively executed, placing them at risk for preventable accidents and injuries. The facility's failure to adhere to its own policies and care plans resulted in these deficiencies, as noted by the surveyors.
Failure to Communicate Resident's Condition with Dialysis Center
Penalty
Summary
The facility failed to consistently communicate a resident's medical condition with the dialysis center, which led to a deficiency in providing safe and appropriate dialysis care. The resident, who required hemodialysis due to end-stage renal disease, had multiple medical conditions including sleep apnea, diabetes mellitus, hypertension, congestive heart failure, bipolar disorder, depressive disorder, Parkinson's disease, chronic obstructive pulmonary disease, and dysphagia. The resident's care plan specified that dialysis was to be conducted three times a week, with specific instructions for pre- and post-dialysis assessments and communication with the dialysis center. However, the facility's records lacked evidence of pre-hemodialysis assessments on several specified dates and post-hemodialysis assessments on other dates. Interviews with nursing staff revealed that there was an expectation for nurses to fill out and send pre-dialysis communication sheets with the resident and ensure post-dialysis sheets were completed and returned. Despite these expectations, the facility's failure to consistently follow these procedures placed the resident at risk of potential adverse outcomes and physical complications related to dialysis.
Failure to Provide Dementia-Related Care Services
Penalty
Summary
The facility failed to provide appropriate dementia-related care services for a resident, identified as R99, who was diagnosed with dementia, general anxiety disorder, and cognitive communication disorder. The resident's care plan indicated the need for an interpreter due to her non-English language communication and required staff to encourage her independence while ensuring supervision, especially when outside. Despite these instructions, staff did not utilize translation services or cue cards to communicate effectively with R99 during incidents of confusion and wandering. On multiple occasions, R99 exhibited behaviors such as wandering into other residents' rooms and attempting to assist them, which led to confusion and distress among the residents. Staff interventions were inadequate as they attempted to redirect R99 in English, which she did not understand, and failed to use available translation services. This lack of effective communication and supervision resulted in R99's continued wandering and interactions with other residents, which were not appropriately managed. The facility's policy required staff to provide assistance and services as outlined in each resident's care plan and to monitor and update care plan interventions as needed. However, the staff did not adhere to these guidelines, as evidenced by their failure to use translation services and adequately supervise R99, leading to a deficiency in providing dementia-related care. This deficiency placed R99 at risk for decreased quality of life, isolation, and impaired dignity.
Failure to Reconcile Controlled Substances Between Shifts
Penalty
Summary
The facility failed to ensure that controlled substances were properly accounted for and reconciled between shifts, as evidenced by missing signatures on the Narcotic Hand Off Count Sheets for multiple dates in July, August, and September 2024. Specifically, there were missing signatures for either the on-coming or off-going nurse during both morning and evening shifts on several occasions. This lack of documentation was observed in the medication rooms and carts on the 100 halls, indicating a failure to adhere to the facility's policy requiring narcotic counts and signatures at each shift change. Interviews with facility staff, including a Certified Medication Aide and a Licensed Nurse, confirmed that narcotics were supposed to be counted and documented with signatures at each shift change. The facility's policy on Controlled Substance Administration and Accountability, dated January 1, 2020, mandates safeguards to prevent loss, diversion, or accidental exposure of controlled substances. Despite this policy, the facility did not ensure accurate reconciliation of controlled medications, placing residents at risk for medication misappropriation and diversion.
Failure to Address Medication Regimen Irregularities
Penalty
Summary
The facility failed to ensure that the Consultant Pharmacist (CP) identified and reported missing dosage and application location for a physician-ordered medication for a resident, referred to as R92. R92 had multiple diagnoses, including quadriplegia, dementia, and encephalopathy, and required significant assistance for daily activities. The resident's medication orders for diclofenac sodium external gel lacked specific dosage amounts and application locations, which were not identified or reported by the CP during monthly medication regimen reviews from May 2024 to August 2024. This oversight placed the resident at risk for unnecessary medication side effects. Additionally, the facility did not ensure that the CP's recommendations for another resident, referred to as R35, were submitted to the attending physician for review. R35 had severe cognitive impairment and multiple diagnoses, including diabetes mellitus, depressive disorder, atrial fibrillation, and hypertension. The resident's electronic medical record showed that recommendations were made by the CP in March and May 2024, but there was no evidence that these recommendations were reviewed or addressed by the attending physician. This failure to act on the CP's recommendations placed R35 at risk for unnecessary medication use and potential side effects. Interviews with facility staff revealed a lack of clarity and action regarding pharmacy recommendations. Licensed Nurse J stated she was not involved with pharmacy recommendations, and Administrative Nurse D confirmed that the facility could not locate documentation showing that the physician had reviewed the CP's recommendations for R35. The facility's Medication Regimen Review policy required thorough evaluation and documentation of medication regimens, but these procedures were not followed, leading to the deficiencies identified in the report.
Deficiency in Medication Administration for a Resident
Penalty
Summary
The facility failed to ensure that a resident's medication regimen was free from unnecessary drugs, specifically regarding the administration of diclofenac, a topical medication used to treat pain and swelling. The resident, identified as R92, had a physician's order for diclofenac sodium external gel 1% to be applied to the affected area three times a day for pain. However, the order lacked a specified dosage amount and did not indicate the specific location for application. This oversight placed the resident at risk of unnecessary medication administration and potential adverse side effects. R92's medical history included diagnoses of quadriplegia, dementia, and encephalopathy, with a documented severely impaired cognition. The resident required substantial to total assistance for functional abilities and was always incontinent of both bladder and bowel. During the survey, it was observed that the licensed nurse applied the medication without a specified dosage, and the administrative nurse confirmed that all orders should indicate the amount and area for application. The facility was unable to provide a policy regarding physician's orders when requested, highlighting a deficiency in ensuring proper medication administration for R92.
Lack of Collaboration with Hospice Services
Penalty
Summary
The facility failed to ensure proper collaboration and communication between the nursing home and hospice services for two residents, R20 and R5, who were receiving hospice care. For R20, the facility did not document a comprehensive care plan that included the medications covered by hospice, personal care items provided, and the frequency of hospice visits. The hospice communication book also lacked a current hospice care plan, physician order with admitting diagnosis, and a list of medications covered by hospice. This lack of documentation and communication created a risk of missed opportunities for services and delayed addressing of physical, mental, and psychosocial needs. R20's medical history included dementia, major depressive disorder, diabetes mellitus, and chronic obstructive pulmonary disease. Observations noted that R20 had severely impaired cognition and required assistance with activities of daily living. Despite being admitted to hospice care, the facility's care plan did not reflect the necessary coordination with the hospice provider, as evidenced by the absence of detailed documentation regarding hospice services. Similarly, for R5, the facility's care plan did not specify the services provided by hospice, such as medication, equipment, and supplies, or the schedule of hospice worker visits. R5's medical conditions included convulsions, bipolar disorder, depressive disorder, anxiety, cerebral infarction, Bell's palsy, protein-calorie malnutrition, weakness, dysphagia, and congestive heart failure. Despite receiving hospice services, the facility failed to ensure a collaborative process was in place to communicate necessary information regarding R5's care, which had the potential for negative outcomes.
Failure to Obtain Informed Declination for PCV20 Vaccine
Penalty
Summary
The facility failed to offer and/or obtain an informed declination for the Pneumococcal Conjugate Vaccine (PCV20) for two residents, identified as R35 and R75. Both residents' Electronic Medical Records (EMR) documented a refusal for the PCV20 vaccination, yet their clinical records lacked evidence of an informed declination. This deficiency was identified during a review of the facility's immunization practices, which included a sample of 26 residents out of a census of 115. The facility's Vaccine Information Statement, revised on 06/01/22, mandates that a copy of the most current vaccine information statement be provided to the resident or their legal representative before vaccine administration, and that a signed consent form be placed in the individual's permanent medical record. However, the facility was unable to provide evidence of informed declinations for R35 and R75, placing them at increased risk for complications related to pneumonia.
Failure to Post Daily Staffing Information and Maintain Records
Penalty
Summary
The facility failed to comply with the requirement to post daily staffing information, including the census, and to maintain these records for 18 months. During an inspection on 09/16/24, it was observed that the staffing sheet displayed in the main lobby was dated 09/13/24 and did not include the census. The following day, the posted staffing sheet had the correct date but still lacked the census information. A review of the facility's records from 04/01/23 to 09/16/24 revealed multiple missing daily posted staffing records between 07/12/23 and 12/01/23. Administrative Nurse D confirmed the requirement to post daily staffing hours with the census and maintain these records for 18 months. The facility was unable to provide a policy related to the posting of staffing information.
Failure to Prevent Falls and Provide Post-Fall Care
Penalty
Summary
The facility failed to identify and implement appropriate, resident-centered interventions to prevent falls for a cognitively impaired resident. Despite multiple falls and documented interventions, the resident continued to fall, indicating that the interventions were ineffective. The resident's care plan included measures such as staff education, medication review, and placing signs in the resident's room, but these did not prevent further falls. On one occasion, the resident experienced an unwitnessed fall that resulted in head trauma. The facility failed to ensure that the resident received post-fall care, including neurological evaluations and nursing assessments. Although initial neurological checks were performed, there was a lack of evidence that these checks were continued as required. The resident was later found to have nasal bone fractures and multiple rib fractures. Interviews with staff revealed inconsistencies in the implementation of post-fall protocols. One nurse did not check if the resident was on anticoagulant medication, which would have necessitated immediate hospital transfer. Another nurse did not receive a callback from the on-call provider and did not attempt to call again. These lapses in care placed the resident at risk for increased pain and other complications.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Shawnee
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Westchester Village Of Lenexa | 1.5 mi | ★★★★★ | 0 | 0 |
| Garden Terrace At Overland Park | 1.5 mi | ★★★★★ | 4 | 2 |
| Brookdale Rosehill | 2 mi | ★★★★★ | 15 | 0 |
| Lakeview Village | 2.2 mi | ★★★★★ | 15 | 0 |
| Merriam Gardens Healthcare & Rehabilitation Center | 2.3 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.