Spring Hill Care And Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Spring Hill, Kansas.
- Location
- 251 E Wilson Avenue, Spring Hill, Kansas 66083
- CMS Provider Number
- 175425
- Inspections on file
- 17
- Latest survey
- November 18, 2025
- Citations (last 12 mo.)
- 9 (1 serious)
Citation history
Health deficiencies cited at Spring Hill Care And Rehab during CMS and state inspections, most recent first.
Staff did not promptly inform a resident, the resident's doctor, and a family member about important events such as injury, decline, or room changes that affected the resident.
The facility did not ensure that a resident received both routine and 24-hour emergency dental care as required, resulting in unmet dental needs.
The facility did not employ a full-time certified dietary manager to oversee food and nutrition services for 36 residents. Instead, a dietary staff member was still in training to become a CDM, and the RD visited only monthly, which did not meet the facility's policy for staffing with appropriate competencies.
The facility did not complete a thorough assessment to determine required staffing levels and resources for competent care during daily operations and emergencies. The assessment lacked details on the number of RNs, LPNs/LVNs, CMAs, and CNAs needed for each unit and shift, and did not address patient acuity or census. Staffing data showed low weekend coverage, and administrative staff confirmed the assessment was incomplete, affecting all residents.
Surveyors found that pressurized oxygen tanks were not secured in a locked area, making them accessible to cognitively impaired, independently mobile residents. Additionally, two residents with severe cognitive impairment and a history of falls did not have required fall prevention interventions in place, such as accessible call lights, fall mats, and nonskid strips, despite these being outlined in their care plans. Staff confirmed knowledge of these requirements, but interventions were not consistently implemented.
Surveyors found that several residents' respiratory equipment, including CPAP masks, a nebulizer mask, and a nasal cannula, were not stored in a sanitary manner, with items left on the floor, draped over machines, or hung on message boards. Additionally, clean linens were transported with bath blankets exposed on top of a covered cart. Staff interviews revealed inconsistent knowledge of proper procedures, and the facility lacked a policy for respiratory equipment storage.
A resident with severe cognitive impairment and incontinence was left in urine-soaked clothing after breakfast and repeatedly called out for help, but staff delayed providing incontinence care for ten minutes despite the resident's visible distress. Staff interviews confirmed that immediate assistance should have been provided to maintain dignity.
A resident with severe dementia and a history of inappropriate sexual behaviors was able to inappropriately touch another cognitively impaired resident in a common area without immediate staff intervention. Despite care plan instructions and staff awareness of the need for supervision, the resident was left unsupervised, resulting in an incident of sexual abuse.
A resident was administered Cymbalta, an antidepressant, without a documented indication for use, despite facility policy and staff expectations that all medications require an indication. The resident had intact cognition and multiple diagnoses, and staff interviews confirmed that orders lacking an indication should be clarified, but this was not done.
A resident with multiple medical conditions and significant care needs was not accurately documented as requiring a CPAP device on the MDS assessment. The resident's care plan and CAA also lacked mention of the CPAP, despite confirmation from staff and medical records of its use. This omission resulted in an incomplete reflection of the resident's status and needs.
A resident with severe cognitive impairment and dysphagia continued to have a care plan listing a therapeutic diet with pureed meat, despite a current dietary order and observed practice of providing a mechanically soft diet with chopped meat. Staff confirmed care plans should be updated to reflect changes, but the care plan was not revised to match the resident's actual dietary needs.
A resident with severe cognitive impairment and dysphagia continued to have a care plan listing a therapeutic diet that did not match the current dietary order, which specified a mechanically soft diet with chopped meat. Staff provided meals according to the updated order, but the care plan was not revised to reflect this change, resulting in a discrepancy between documented and provided care.
A resident with hemiparesis, dementia, and respiratory issues was left lying flat in bed while attempting to eat without staff assistance, and the call light was not within reach. Facility records and staff interviews confirmed that the resident required supervision and setup help with eating, and that call lights should always be accessible, but these protocols were not followed.
Two residents at risk for pressure ulcers did not receive proper use of pressure-reducing equipment and interventions. One resident's low air-loss mattress was set incorrectly and was found deflated, while another resident did not have heel protector boots applied as required, with staff failing to consistently implement these interventions according to care plans and facility policy.
A resident with multiple medical conditions and moderate cognitive impairment had a CPAP mask that was not stored in a sanitary manner, as it was found draped over the machine without a clean barrier or container. Staff interviews revealed inconsistent practices and a lack of clear policy or documentation regarding the cleaning and storage of respiratory equipment.
A resident with severe dementia and a history of falls was not provided with proper supervision or accident prevention measures, as required by her care plan. The call light was found out of reach, and the resident was involved in an incident of inappropriate contact with another resident. Staff confirmed that residents with dementia should have call lights within reach and be frequently monitored, but these measures were not consistently implemented.
A consultant pharmacist did not identify or report missing indications for administration on several medication orders and failed to note the lack of required heart rate monitoring for an antihypertensive medication for a resident with multiple diagnoses. Nursing staff confirmed that all medications should have indications and that physician-ordered monitoring should be followed, but these requirements were not met or reported as irregularities by the pharmacist.
A resident was administered antihypertensive and other medications without documented indications, and required heart rate monitoring was not consistently performed as ordered by the physician. Pharmacy reviews and facility documentation failed to identify or address these issues, and staff interviews confirmed that medication indications and monitoring parameters were not followed as required.
A resident with severe cognitive impairment and multiple diagnoses was receiving hospice services, but the facility failed to document the medications and equipment provided by hospice in the care plan. Staff interviews confirmed that this information should have been included and accessible, but it was missing, contrary to facility policy and expectations.
The facility did not post its updated daily nurse staffing sheet as required, with the most recent form displayed being several days old. Staff interviews confirmed that nursing staff and the charge nurse were responsible for this task, but the daily update was not completed according to facility policy.
The facility did not submit accurate weekend staffing coverage hours to CMS through Payroll Based Journaling, despite internal records showing no staffing gaps. Staff interviews revealed mixed perceptions about weekend staffing adequacy, and administrative staff acknowledged occasional gaps and the use of incentives for shift coverage. The facility's assessment also lacked specific staffing requirements for each unit and shift.
Failure to Notify Resident, Physician, and Family of Significant Events
Penalty
Summary
Facility staff failed to immediately notify the resident, the resident's physician, and a family member about situations that affected the resident, such as injury, decline, or changes in room assignment. This lack of timely communication was observed and documented by surveyors as a deficiency in the facility's process for keeping residents and their representatives informed about significant events impacting the resident's well-being.
Failure to Provide Routine and Emergency Dental Care
Penalty
Summary
The facility failed to provide routine and 24-hour emergency dental care for each resident as required. This deficiency indicates that residents did not have access to necessary dental services, both for regular care and urgent dental needs, as stipulated by regulations. No additional details about specific residents, their medical history, or the circumstances at the time of the deficiency are provided in the report.
Lack of Full-Time Certified Dietary Manager
Penalty
Summary
The facility failed to provide the services of a full-time certified dietary manager for its census of 36 residents who received meals from the kitchen. At the time of the survey, the dietary staff member responsible for managing food and nutrition services was still in training to become a Certified Dietary Manager (CDM), and the Registered Dietician (RD) only visited the facility monthly. The facility's own policy required sufficient staff with appropriate competencies and skill sets to carry out food and nutrition service functions, but this standard was not met as there was no full-time certified dietary manager on staff.
Failure to Conduct Comprehensive Facility-Wide Resource Assessment
Penalty
Summary
The facility failed to conduct a thorough facility-wide assessment to determine the necessary resources for competent resident care during both routine operations and emergencies. The assessment provided by administrative staff was last updated in December 2024 and did not specify the required staffing levels for each unit, nor did it identify the number of RNs, LPNs/LVNs, CMAs, and CNAs needed based on patient acuity and census. Additionally, the assessment lacked details on staffing requirements for each shift, day, and weekend. A review of the facility's Payroll Based Journaling (PBJ) staffing data revealed excessively low weekend staffing during two consecutive quarters. Interviews with administrative staff confirmed that the assessment was recently updated but still did not include the necessary staffing requirements as outlined by CMS. The facility's own policy, revised in January 2017, requires a documented assessment to determine resources needed for care during all operational periods, including evenings, nights, and weekends. This deficiency affected all 36 residents in the facility.
Failure to Secure Oxygen Tanks and Implement Fall Interventions
Penalty
Summary
Surveyors identified that the facility failed to secure pressurized supplemental oxygen tanks in a locked area, leaving 35 oxygen cylinders accessible in an unsecured storage room. The room had a key lock, but it was not secured at the time of observation, making the tanks accessible to 22 cognitively impaired, independently mobile residents. Staff interviews confirmed that facility policy required oxygen tanks to be stored in a locked room, and all interviewed staff acknowledged this expectation. Additionally, the facility did not ensure that fall prevention interventions were in place for two residents with severe cognitive impairment and significant physical limitations. One resident, with diagnoses including dementia, major depressive disorder, and a history of hip fracture, was found in bed with her call light on the floor and her fall mat folded and not in use. Her care plan required the call light to be within reach and the fall mat to be in place. Another resident, also with severe cognitive impairment and a history of falls, was observed with her call light on the floor, her fall mat folded at the head of the bed, and no nonskid strips in her bathroom, despite these being specified interventions in her care plan. Staff interviews revealed that all nursing staff had access to care plans and were responsible for ensuring fall interventions were in place before leaving a resident's room. Facility policy required staff to implement individualized fall prevention measures based on each resident's risk factors. Despite these policies and staff awareness, required interventions were not consistently implemented for the residents reviewed.
Failure to Maintain Sanitary Storage of Respiratory Equipment and Linens
Penalty
Summary
Surveyors identified that the facility failed to store respiratory equipment for four residents in a sanitary manner. Specifically, one resident's CPAP mask was draped over the CPAP machine without a clean barrier or sanitary container, another resident's CPAP mask was found on the floor next to the bed, and a third resident's nebulizer mask was hung from a thumb tack on a message board. Additionally, a fourth resident's nasal cannula was draped over a wheelchair without proper containment. These observations were made during a facility walkthrough and were confirmed by staff interviews, which revealed inconsistent knowledge and practices regarding the proper storage of respiratory equipment. The facility also failed to transport linens in a sanitary manner, as observed when laundry staff moved a covered linen cart with bath blankets placed on top, exposing them to potential contamination. Staff interviews indicated uncertainty and lack of clarity regarding the correct procedures for both respiratory equipment storage and linen transport. Furthermore, the facility did not provide a policy for respiratory equipment storage, although a policy for handling clean linen was available, which required clean laundry to be handled in a way that prevents contamination.
Failure to Provide Timely Incontinence Care and Maintain Resident Dignity
Penalty
Summary
A resident with severe cognitive impairment, dementia, benign prostatic hyperplasia, dysphagia, and anxiety disorder was dependent on staff for all activities of daily living, including toileting and personal hygiene. The resident was always incontinent of bowel and bladder and had a care plan in place requiring staff to provide incontinence care every two hours and as needed, as well as to respond promptly when the resident was found to be incontinent. The resident also required cueing and set-up assistance during meals and was at risk for nutritional impairment. On the morning of the incident, the resident was observed in the dining room with urine-soaked pants extending down to the knees after breakfast. The resident approached staff, repeatedly stating he was sticky and needed help, but was asked to sit and wait next to the nurses' cart. Multiple staff members walked past as the resident continued to call out for assistance and stood up several times while waiting. It was not until ten minutes later that the resident was finally escorted to his room for care. Interviews with staff confirmed that incontinence care should have been provided immediately to maintain dignity and prevent discomfort, in accordance with the facility's dignity policy.
Failure to Prevent Resident-to-Resident Sexual Abuse Due to Inadequate Supervision
Penalty
Summary
The facility failed to prevent an incident of resident-to-resident sexual abuse involving two cognitively impaired residents. One resident, who had a diagnosis of dementia, severe cognitive impairment, and a history of inappropriate sexual behaviors, was observed by a licensed nurse groping another severely cognitively impaired resident in a common area. The care plan for the resident with a history of sexual behaviors included instructions for staff to supervise him, monitor his behaviors, and intervene as necessary to protect others, but these interventions were not effectively implemented at the time of the incident. Staff interviews confirmed that residents with behavioral concerns were not to be left unsupervised with others, and that the resident in question required supervision due to his history. Despite documented behavioral risks and care plan interventions, the resident was able to access and inappropriately touch another resident without immediate staff intervention. Both residents involved were unable to recall the incident due to their cognitive impairments. The facility's abuse prevention policy required staff to recognize and report abuse and to manage behavioral symptoms in residents at risk, but the failure to supervise the resident as outlined in his care plan resulted in an episode of preventable abuse.
Psychotropic Medication Administered Without Indication
Penalty
Summary
The facility failed to ensure that a resident's psychotropic medication, specifically Cymbalta (an antidepressant), had an appropriate indication for administration as required. Review of the resident's electronic medical record showed an active order for Cymbalta without a documented reason for its use. The resident's diagnoses included hypertension, major depressive disorder, gallbladder calculus, and diabetes mellitus. Both annual and quarterly Minimum Data Set (MDS) assessments indicated the resident had intact cognition and was receiving multiple classes of medications, including psychotropics. The care plan documented staff education on proper medication administration, but did not address the lack of indication for the psychotropic medication order. Interviews with facility staff confirmed that every medication order should include an indication for use, and that orders lacking this information should be clarified. The facility's policy on chemical restraints and unnecessary psychotropic medications required that such medications only be used to treat specific medical symptoms and not for staff convenience or discipline. Despite these policies and staff expectations, the resident continued to receive Cymbalta without a documented indication, constituting a failure to comply with regulatory requirements for medication management.
Failure to Document CPAP Use on MDS Assessment
Penalty
Summary
The facility failed to accurately document a resident's use of a continuous positive airway pressure (CPAP) device on the comprehensive Minimum Data Set (MDS) assessment. The resident, who had a history of acquired absence of the right foot, sacral pressure ulcer, hematogenous osteomyelitis, lack of coordination, muscle weakness, and anxiety, was admitted with multiple care needs and required significant assistance with activities of daily living. The MDS assessment did not indicate the resident's need for a CPAP, despite the resident's medical record and staff interview confirming its use. Further review of the resident's care plan and Care Area Assessment (CAA) showed no mention of the CPAP device, even though the resident was dependent on staff for most care and had complex medical conditions. The facility's comprehensive assessment policy required accurate and timely assessments reflective of the resident's status, but this was not met in the case of the CPAP documentation. An administrative nurse confirmed that all CPAPs should be indicated on the MDS, highlighting the omission.
Failure to Update Care Plan to Reflect Current Dietary Orders
Penalty
Summary
The facility failed to revise the care plan for a resident with multiple medical diagnoses, including BPH, anxiety disorder, dysphagia, and dementia, to accurately reflect his current dietary needs. The resident's care plan, initiated in 2022, indicated a regular, mechanically soft diet with pureed meat texture and thin liquids due to swallowing difficulties. However, the active dietary order in the electronic medical record, dated later, specified a regular, mechanically soft diet with chopped meat texture. During observation, the resident was provided a meal with chopped meat consistency and consumed it without swallowing concerns, but the care plan was not updated to match this change. Interviews with nursing staff and administrative personnel confirmed that care plans are intended to be updated quarterly or as changes occur, and should accurately reflect each resident's current care needs, including diet type and consistency. The facility's policy requires comprehensive assessments and individualized interventions, with care plans reviewed and updated to reflect any changes. Despite these procedures, the resident's care plan was not revised to remove the therapeutic diet, resulting in a discrepancy between the care plan and the actual dietary order provided.
Failure to Update Care Plan for Dietary Changes
Penalty
Summary
The facility failed to revise the care plan for a resident with multiple medical diagnoses, including benign prostatic hyperplasia, anxiety disorder, dysphagia, and dementia, to accurately reflect his current dietary needs. The resident's care plan, initiated in 2022, continued to indicate a regular, mechanically soft diet with pureed meat texture and thin liquids, despite an active dietary order from May 2025 specifying a regular, mechanically soft diet with chopped meat texture. Observations confirmed that the resident was provided and consumed a chopped meat consistency meal without swallowing concerns, but the care plan was not updated to match this change. Interviews with nursing staff and administrative personnel revealed that care plans were intended to be updated quarterly or as changes occurred, and that all staff had access to view and review these plans. The facility's policy required care plans to be individualized and updated to reflect any changes in the resident's goals and care needs. However, the failure to revise the care plan to remove the therapeutic diet and accurately document the current dietary order resulted in a discrepancy between the resident's actual care and the documented plan.
Failure to Provide Assistance with Eating and Ensure Call Light Accessibility
Penalty
Summary
A deficiency was identified when a resident with a history of hemiparesis following a cerebrovascular accident, pulmonary edema, dementia, and other significant medical conditions did not receive appropriate assistance with eating and did not have their call light within reach. The resident was observed lying flat in bed while attempting to eat oatmeal without staff assistance, despite physician orders to keep the head of the bed elevated due to respiratory failure and pulmonary edema. The call light was found wrapped around the trapeze arm, out of the resident's reach, and no staff were present to monitor or assist during the meal. Facility records indicated that the resident required supervision and setup or cleanup assistance with eating, and was dependent on staff for all other activities of daily living. Interviews with nursing staff confirmed that call lights should always be within reach and that residents should not be laid flat while eating. The facility's policy also required staff to assist residents unable to perform activities of daily living. Despite these requirements, the resident was left unattended, in a flat position, and without access to the call light during mealtime.
Failure to Implement and Monitor Pressure Ulcer Prevention Interventions
Penalty
Summary
The facility failed to ensure proper use of pressure-reducing equipment and interventions for two residents at risk for pressure ulcers. One resident, with a history of pressure ulcers, limited mobility, and a low body weight, was observed with her low air-loss mattress set incorrectly at a much higher weight than her actual weight and, on one occasion, with the mattress deflated and the control panel turned off. Staff interviews revealed uncertainty about why the mattress was off and inconsistent practices regarding checking and setting the mattress according to the resident's weight, despite facility policy requiring these checks each shift. Another resident, who was dependent on staff for all activities of daily living and had multiple medical conditions including hemiparesis, dementia, and a history of skin breakdown, was observed multiple times lying in bed with his heels directly on the mattress, despite care plan instructions and physician orders for the use of heel protector boots to offload pressure. The boots were found on the bed or bedside table rather than on the resident. Staff interviews indicated that both nurses and CNAs were aware of the need to float the resident's heels or apply boots, but the intervention was not consistently implemented. The facility's policies required identification and implementation of preventative interventions for residents at risk for pressure injuries, as well as ongoing monitoring to ensure effective prevention and care. However, the observed failures to use pressure-relieving devices as intended and to follow care plan interventions for both residents constituted deficiencies in pressure ulcer prevention and care.
Failure to Store CPAP Mask in a Sanitary Manner
Penalty
Summary
The facility failed to ensure the continuous positive airway pressure (CPAP) mask for a resident was stored in a sanitary manner. The resident had multiple medical conditions, including an acquired absence of the right foot, pressure ulcer, osteomyelitis, muscle weakness, and moderately impaired cognition. The resident was dependent on staff for most activities of daily living and used a wheelchair. Despite the resident's complex medical needs, the care plan and electronic medical record did not include instructions for the use, cleaning, or sanitary storage of the CPAP device. During observation, the CPAP mask was found draped over the CPAP machine without a clean barrier or sanitary container. Interviews with nursing staff revealed inconsistent knowledge and practices regarding the proper storage of respiratory equipment, with some staff stating the mask should be placed in a plastic bag or drawer, and others indicating it was the responsibility of nursing staff to ensure sanitary storage. The facility did not have a respiratory storage policy available.
Failure to Provide Adequate Supervision and Accident Prevention for Resident with Dementia
Penalty
Summary
A resident with a diagnosis of dementia, severe cognitive impairment (BIMS score of zero), history of falls, muscle weakness, and other comorbidities was not provided with appropriate supervision and accident prevention services. The resident's care plan required that the call light be kept within reach and the door remain open for easier monitoring due to a history of unassisted walking and falls. However, observations revealed that the call light was found on the floor and not within the resident's reach, contrary to the care plan and facility policy. Staff interviews confirmed that call lights should always be accessible to residents with dementia and that such residents require frequent monitoring. Additionally, an incident occurred in which the resident was found in a common area with another resident who was observed groping her breast. Both residents were immediately separated, and neither recalled the incident when interviewed. The facility's documentation and staff statements indicated that the resident with dementia was severely impaired and unable to understand or communicate effectively, further emphasizing the need for close supervision. The failure to ensure the resident's call light was accessible and to provide adequate supervision placed the resident at risk for preventable accidents and incidents.
Consultant Pharmacist Failed to Identify and Report Medication Order Irregularities
Penalty
Summary
The facility failed to ensure that the Consultant Pharmacist (CP) identified and reported irregularities in a resident's medication regimen. Specifically, the CP did not note the absence of indications for administration on physician orders for several medications, including Ursodiol, Tamsulosin, and Cymbalta. Additionally, the CP did not identify or report that the physician's order for Metoprolol, an antihypertensive medication, required heart rate monitoring prior to administration, and that this monitoring was not documented as completed for 61 out of 100 days reviewed. The Monthly Medication Reviews (MMRs) over a one-year period did not reflect that these irregularities were identified or reported by the CP. The resident involved had diagnoses including hypertension, major depressive disorder, gallbladder calculus, and diabetes mellitus, and was receiving multiple classes of medications such as anticoagulants, antidepressants, antianxiety agents, antiplatelets, diuretics, opioids, and hypoglycemics. Interviews with nursing staff confirmed that all medications should have an indication for administration and that specific monitoring parameters ordered by the physician should be followed. The facility's policy required the CP to review medication regimens and report irregularities, but this was not done in the case reviewed.
Failure to Ensure Physician Parameters and Indications for Medication Administration
Penalty
Summary
The facility failed to ensure that a resident’s drug regimen was free from unnecessary medications by not following physician parameters for a prescribed antihypertensive medication and by administering medications without documented indications. Specifically, the resident’s electronic medical record showed orders for Ursodiol and Tamsulosin that lacked indications for administration. Additionally, the order for Metoprolol succinate, an antihypertensive, included a directive to hold the medication if the systolic blood pressure was less than 110 mm Hg or the heart rate was less than 60 beats per minute, but there was no evidence that heart rate monitoring was consistently performed as ordered. Review of the resident’s Medication Administration Record and other documentation over a 100-day period revealed that heart monitoring was not documented for 61 days, despite the physician’s order requiring it prior to administration of Metoprolol. The Monthly Medication Reviews from the pharmacy also failed to identify or address the lack of indications for certain medications and the absence of required heart monitoring for the antihypertensive medication. The care plan and facility policy required staff to administer medications as ordered and to ensure every medication had an appropriate indication, but these requirements were not met in this case. Interviews with nursing staff and administration confirmed that all medications should have a documented indication and that physician parameters, such as heart rate monitoring, should be followed. Despite these expectations and policies, the facility did not ensure compliance, resulting in the administration of medications without proper indications and without following monitoring parameters as ordered by the physician.
Failure to Document Hospice-Provided Medications and Equipment
Penalty
Summary
The facility failed to provide a description of the medication and equipment supplied by hospice for a resident receiving hospice services. The resident, who had diagnoses including dementia, major depressive disorder, and cognitive communication deficit, was documented as being severely cognitively impaired and dependent on staff for mobility and personal care. The care plan indicated that hospice would provide nursing visits, a bath aide, social services, and chaplain visits, but did not specify the medications and equipment provided by hospice. Staff interviews revealed that information about hospice services should be included in the resident's care plan and accessible to all staff, but this information was missing. Observations and record reviews confirmed that the hospice provider supplied a notebook for each hospice resident, but the care plan lacked details about the specific services, supplies, and equipment provided by hospice. Staff members, including a licensed nurse and a CNA, stated that the care plan should include this information, and the administrative nurse confirmed that all staff should have access to it. The facility's policy required coordination and documentation of hospice services, but this was not followed, resulting in incomplete information in the resident's care plan.
Failure to Post Updated Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post its updated daily nurse staffing information as required. During an inspection, the Direct Care Report form displayed across from the nurse's station was found to be dated three days prior to the inspection date, indicating it had not been updated daily. Interviews with a licensed nurse and an administrative nurse confirmed that nursing staff and the charge nurse were responsible for updating and posting the staffing form each day. A review of the facility's staffing policy indicated that staffing hours must be maintained and made available upon request, but the daily posting requirement was not met at the time of the survey.
Failure to Accurately Report Weekend Staffing Data to CMS
Penalty
Summary
The facility failed to submit accurate direct care staffing information to the Centers for Medicare and Medicaid Services (CMS) through Payroll Based Journaling (PBJ), specifically regarding weekend staffing coverage hours. Although the facility's internal records, including working schedules, time sheets, and posted staffing hours, showed no gaps or loss of hours, the PBJ data submitted for two consecutive fiscal quarters triggered for excessively low weekend staffing. Interviews with staff indicated that while some did not perceive issues with weekend staffing, administrative staff acknowledged occasional gaps and the use of incentives or shift coverage to address open positions. The administrator noted a recent switch to a new tracking system and stated that the facility had been triggered for low weekend staffing multiple times despite being adequately staffed according to their records. Additionally, the facility's most recent Facility Assessment did not specify the required staffing levels for each unit, nor did it identify the number of RNs, LPNs/LVNs, CMAs, and CNAs needed per unit, patient acuity, or census. The assessment also lacked details on staffing levels required for each shift, day, and weekend. The facility's policy requires that staffing and census information be reported electronically to CMS and made available to residents, family members, and the public within 24 hours of a request.
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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