Below average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Healthcare Resort Of Kansas City during CMS and state inspections, most recent first.
A resident with COPD, PTSD, depression, schizophrenia, cognitive communication deficit, and DM reported that an LPN and a CNA made fun of his body and speech, causing him sadness and anger and fear of retaliation. Resident council minutes showed other residents also feared speaking up because staff might treat them worse, but the resident’s record lacked evidence the allegation was investigated or resolved before the survey. Facility staff later acknowledged they had not reviewed the council minutes and were not aware of the concerns.
Failure to Report Resident Abuse Allegation: A resident stated that an LPN made fun of him, but he feared retaliation and did not report it. The concern was documented in resident council minutes, yet the facility had no evidence it was investigated, resolved, or reported to the SA before survey. Staff also acknowledged they had not reviewed the minutes and should have followed up on resident concerns.
Failure to investigate an abuse allegation and protect a resident from possible retaliation. Resident council minutes documented that a resident said an LPN made fun of him and he feared staff would retaliate if he complained. The clinical record lacked evidence of follow-up, resolution, psychosocial monitoring, or other action, and staff later acknowledged the concern was not reviewed until surveyors identified it.
The facility failed to ensure annual performance evaluations were completed for four CNA/CMA staff reviewed. Record review showed multiple staff had no yearly evaluation available, and one evaluation lacked a date and signature. An administrative staff member stated department heads were responsible for completing the evaluations, and the facility could not provide a related policy.
Staff failed to maintain infection control practices when respiratory equipment was left in unsanitary locations, wet briefs were left in a trash can, clean linen was placed on a PPE cart, soiled laundry was handled after being picked up from the floor, and hand hygiene was not performed between dirty and clean tasks. An LPN also placed a blood glucose monitor on a bed rail without a clean barrier, and a resident’s nasal cannula was found lying in a wheelchair seat instead of being stored in a sanitary container.
The facility failed to ensure agency staff completed required communication training. Record review showed no documentation that agency CNA P, CNA Q, and an LN had completed the training, and Administrative Staff B stated the facility expected the agency to have already provided the required in-services before scheduling staff. The facility also could not provide a policy on required staff in-services.
The facility failed to ensure agency CNA P, CNA Q, and LN K had documentation of required resident rights training. Administrative Staff B stated the facility expected the agency to have already provided the required training and in-services before scheduling agency staff, and the facility could not provide a policy related to staff required in-services.
The facility failed to ensure an agency CNA had completed required behavioral health training. Record review showed no documentation of the training, and Administrative Staff B stated the facility expected the agency to provide required training and in-services before scheduling staff. The facility also could not provide a policy related to required staff in-services.
The facility failed to maintain a safe, clean, and homelike environment when missing tiles/bricks were observed at the entrance walkway, ants were seen crawling on a table in the east dining room, and a resident's bed light was not working. Dietary staff said the ants had been reported, and maintenance said pest control had come out and a work order had been placed for the walkway repair, while the resident stated the light had not worked since admission.
Failure to provide consistent bathing assistance for dependent residents. Three residents with significant physical impairments and, for two of them, cognitive impairment, were dependent on staff for bathing or showering. Records showed missed or inconsistent bathing documentation, use of NA entries, and limited showers or baths despite scheduled preferences. On observation, residents had dirty hair, beard, and fingernails, and one resident stated she had not had a shower since admission and wanted one.
Medication Error Rate Exceeded Allowed Threshold: A CMA administered 7 of a resident’s 14 meds outside the allowed time window, resulting in a 21.88% med error rate. The resident received multiple late meds, including vitamin C, buspirone, hydralazine, pantoprazole, baclofen, eye drops, and ipratropium nasal spray. The CMA stated he was running behind and trying to give residents’ meds correctly and efficiently.
Pest control failed when ants were observed crawling across a table in the east dining room. Dietary staff reported the ants to maintenance, and staff and admin said pest control was used monthly and as needed, with an order entered in TELS and a call placed for service after the ants were reported. The facility’s pest control policy required an environment free of pests, frequent treatment, additional visits when needed, and staff monitoring.
A facility failed to keep call lights within reach for two residents with significant cognitive and physical impairments. One resident with hemiparesis, vascular dementia, and Parkinson’s disease was observed in a Broda chair while his soft-touch call light was placed out of reach, and he was unable to access it. Another resident with aphasia, a G-tube, CVA, severely impaired cognition, and dependence for all ADLs had her call light hanging behind the bed and out of reach. Staff stated call lights should always be within residents’ reach.
Failure to complete discharge documentation and ombudsman notification: A resident with chronic pain and COPD was discharged home with medications and personal belongings, and discharge instructions were reviewed with no concerns voiced. However, staff could not locate a discharge summary or recapitulation of the resident’s stay, and social services reported only sending hospital transfer lists to the ombudsman rather than the resident’s discharge information.
A resident with severe cognitive impairment, hemiplegia, vascular dementia, and Parkinson’s disease was not provided individualized activity support despite a care plan calling for staff to invite him to activities, provide one-to-one bedside visits, and use items from his red activity bag for redirection. Surveyors observed the resident sitting alone for meals and being returned to his room without one-to-one interaction or use of the activity bag. Staff interviews confirmed the resident had not attended many activities, was considered disruptive in group settings, and that staff should still offer activities and provide items from the red bag when he was not participating.
Failure to provide ordered pressure-relieving devices and heel protection. A resident with severe cognitive impairment, diabetes, stroke-related deficits, and stage 4 heel pressure ulcers was observed without the ordered boot on one heel, while staff stated boots should be applied and maintained by CNA and LN staff. Another resident with aphasia, CVA, and a G-tube was observed in bed with both heels resting directly on the mattress despite an order for Prafo boots at all times. A third resident at risk for pressure injuries was using a wheelchair without a cushion or anti-tip devices and reported buttock pain after sitting.
Failure to Apply Left Hand Splint for Contracture Prevention: A resident with hemiparesis/hemiplegia, vascular dementia, left hand contracture, and Parkinson’s disease did not have his resting hand splint applied as ordered for contracture prevention. The TAR documented the splint as not provided, there was no documentation of refusal, and staff interviews showed confusion about who was responsible for applying and checking the brace. Observations found the resident seated with his left fingers curled into the palm and no splint in place.
A facility failed to keep pressurized oxygen cylinders secured in a locked area and properly stored on an oxygen cart, with cylinders observed in an unsecured storage room and one cylinder left on the floor in a resident room. The facility also failed to maintain fall interventions for two residents: one resident with repeated falls and impaired cognition had a wheelchair missing anti-tip devices and a cushion, and another resident with a recent fall had a bed in a high position with the call light out of reach.
A resident with aphasia, CVA, severe cognitive impairment, and a G-tube was observed receiving enteral nutrition while lying in bed with the HOB only slightly elevated, below the ordered 30 to 45 degrees. The resident’s care plan and MD order required HOB elevation at all times during feeding and for 1 hour after, but staff did not position the resident accordingly while the tube feeding was infusing. The resident was dependent for all ADLs and had documented coughing or choking with meals or meds.
PICC Line Removal Not Timely or Fully Documented: A resident with severe cognitive impairment, dependence for all ADLs, and IV antibiotic therapy had a PICC line that was not removed when the antibiotic ended, and nursing documentation showed conflicting removal entries. The chart lacked a physician order for removal, lacked confirmation that the full line including the tip was removed, and lacked documentation of post-removal site inspection or monitoring for complications.
Respiratory equipment was not kept in a sanitary manner for a resident who required BiPAP and continuous O2. The resident had respiratory failure, CHF, sleep apnea, and pneumonia, and staff observed her BiPAP mask and nasal cannula on the floor or otherwise not properly contained when not in use. The resident also stated she did not wear the BiPAP every night and that staff could not always find the mask or knew the settings, while staff confirmed the equipment should be placed in a dated bag when not in use.
Failure to provide effective pain management for a resident with HTN, lupus, contractures, muscle weakness, and rheumatoid arthritis. The care plan called for pain assessments every shift, repositioning, and ordered pain meds, including duloxetine and PRN oxycodone, but the resident was observed yelling for help and stating he was in pain, with the call light out of reach. The resident was documented with excruciating pain, and another resident reported frequent yelling and delayed nursing response; staff interviews confirmed residents should not have to find nursing for assistance.
A resident with dementia, Alzheimer’s disease, anxiety, and major depressive disorder had severely impaired cognition and a care plan calling for staff to provide 1:1 in-room activities, conversation, comfort, and orientation. However, documentation showed only one activity over a 73-day period, and observations found the resident repeatedly reclined alone in a Broda chair near the nurse station, in the dining room, and in his room with the blinds shut and lights off. Staff interviews showed uncertainty about who was responsible for providing activities, and the Activities Director stated she had limited time to do 1:1 visits.
Unlocked Medication Cart Left Unattended: A CMA left a med cart unlocked and unattended while stepping into a resident's room, and the same cart was later found unlocked again while the CMA was cleaning up another med cart. An RN and an admin nurse stated med carts should be locked whenever staff walk away from them, and the facility policy required drugs and biologicals to be stored in locked compartments.
A resident's record showed refusals for PCV20 and influenza vaccines, but there was no documentation that either vaccine was offered or declined, and no record of a historical administration or physician-documented contraindication. An admin nurse could not locate the declination, and another admin nurse stated the admitting nurse was responsible for obtaining consent or declination, with the IP now expected to follow up on immunization documentation.
The facility failed to ensure daily nurse staffing data was posted and that the posted staffing sheets included required information. Review of the staffing postings showed an outdated date on the sheet and missing daily census information on multiple posted forms. An Administrative Nurse stated an Administrative Staff member was responsible for ensuring the sheets were posted, and that the receptionist posted them on weekends using the forms provided.
A resident receiving enteral nutrition experienced an 11.74% weight loss due to the facility's failure to consistently monitor her weight and adjust her nutritional regimen. Despite being at risk, the resident's nutritional needs were not adequately assessed or addressed, and there was a lack of communication and documentation among staff regarding her condition.
The facility failed to ensure agency direct care staff received required communication training, risking impaired care and decreased quality of life for residents. A review revealed that three CNAs lacked evidence of completed communication training. Administrative Staff A assumed the staffing agency ensured completion of required in-services, which was not the case. The curriculum covered various topics but omitted communication, resident rights, and dementia training.
The facility failed to ensure agency CNAs received required resident rights training, as revealed by a review of training records. Administrative Staff A assumed the staffing agency handled this training, but it was not completed, risking impaired care and decreased quality of life for residents.
The facility did not ensure agency CNAs received required dementia training, risking resident care quality. Training records for three CNAs lacked evidence of completed in-service training. Administrative Staff A assumed the staffing agency handled this, leading to missing training in communication, resident rights, and dementia care.
The facility failed to maintain a safe environment by leaving cleaning chemicals accessible, an unsecured CO2 canister, and an unlocked oxygen storage room. Additionally, fall prevention interventions were not followed for two residents, leading to a fall incident. An unsecured oxygen canister was also left in a resident's room, posing a risk for injury.
The facility failed to secure medication and treatment carts, leaving medicated lotions and medications like Cefdinir and Junuvia unsecured. An LN confirmed that carts should be locked when unsupervised, and the facility's policy required safe storage of medications. This deficiency placed residents at risk for medication errors.
The facility failed to follow infection control standards, risking resident safety. Observations showed improper handling of soiled laundry and PPE, with items left on floors and carts. CMAs and CNAs neglected hand hygiene during medication administration and personal care. Staff interviews confirmed these practices violated the facility's infection control policy, which requires routine training.
A resident with a complex medical history, including hemiparesis and cognitive impairment, was not provided with foot pedals for her wheelchair, leaving her vulnerable to injury. Staff interviews confirmed that pedals should have been used when the resident was being pushed by staff, as per the facility's policy on accommodating individual needs.
A resident with a history of hemiplegia and intact cognition threw hot coffee on another resident during a seating disagreement in the dining room. The incident was reported, but no immediate further action was taken to prevent future harm. The facility's policy on abuse prevention was not adequately followed, resulting in a deficiency in protecting residents from abuse.
A resident with intact cognition and mobility impairments threw hot coffee on another resident during a disagreement over seating in the dining room. The facility failed to fully investigate the incident or implement interventions to prevent further occurrences, despite having policies on abuse prevention. This inaction placed residents at risk of harm.
A resident with a UTI and other conditions experienced a delay in care due to the facility's failure to obtain STAT labs as ordered and notify the physician of the delay. Despite multiple attempts to contact the lab, the labs were not collected promptly, and the resident's condition was not adequately monitored or documented. Staff interviews revealed a lack of communication and follow-up, contributing to the delay in treatment.
A resident with multiple medical conditions, including hemiparesis, did not have her leg/ankle brace applied as ordered when out of bed, risking worsening contractures. Despite a physician's order and no documented refusals, staff failed to apply the brace, with a CNA admitting lack of knowledge on how to do so. Interviews confirmed the brace should have been applied, highlighting a deficiency in following care protocols.
A resident with a history of UTIs did not receive proper perineal care due to inadequate hand hygiene by a CNA. The CNA failed to wash hands between glove changes while assisting the resident, contrary to facility procedures. Staff interviews revealed a lack of ongoing hand hygiene training, contributing to the deficiency.
A facility failed to consistently communicate a resident's medical condition before and after hemodialysis, risking adverse outcomes. The resident, with multiple health issues including end-stage renal disease, was not properly assessed on several occasions. Despite a care plan requiring daily checks and communication with the dialysis center, the facility's process was inadequate, leading to incomplete documentation.
A resident with cognitive impairment and aggressive behaviors was not provided with adequate non-pharmacological interventions, as documented in the facility's records. Despite having a care plan and staff training, the facility failed to document or implement strategies to manage the resident's refusal of care and aggression, and did not notify the medical provider of these behaviors.
A resident with dementia exhibited behaviors such as throwing food and pouring hot food on herself, resulting in a burn injury. Despite having a care plan noting her behavioral history, the facility failed to identify a pattern of these behaviors and implement effective interventions. Staff interviews indicated awareness of the behaviors, but the facility lacked a specific dementia care policy, leading to inadequate supervision and intervention during mealtimes.
A facility failed to monitor a resident's blood pressure and pulse as ordered by a physician before administering metoprolol succinate, an antihypertensive medication. The resident, with a history of congestive heart failure and other conditions, was at risk of unnecessary medication administration due to the lack of monitoring. Interviews with staff confirmed that monitoring should have occurred, but the facility's policy was not followed, as shown by missing records in April, May, and June 2024.
The facility did not post daily nurse staffing data with the required information and failed to retain these records as required. Observations showed outdated postings and missing census numbers. Staffing sheets from earlier months were incomplete, and recent sheets lacked census data. Responsibility for posting was divided among staff, but no specific policy was in place, leading to unawareness of the omissions.
A resident with diabetes and amputations did not receive timely and appropriate wound care, leading to a severe infection and the surgical removal of a toe. The facility failed to monitor and treat the wound promptly, resulting in the resident's condition worsening.
Failure to Address Resident Allegation of Verbal Abuse
Penalty
Summary
The facility failed to ensure a resident remained free from staff-to-resident verbal and/or mental abuse when a resident reported during a resident council meeting that an LPN and a CNA made fun of him. The resident had diagnoses including COPD, blindness in the right eye, PTSD, major depressive disorder, schizophrenia, cognitive communication deficit, and DM. His MDS documented a BIMS score of 15, indicating intact cognition, and he used a wheelchair with impairment to both upper extremities. His care plan identified him as at risk for re-traumatization related to PTSD and noted a history of abandonment and physical and emotional abuse in childhood. Resident council minutes documented that some residents feared nurses and nurse aides would treat them worse if they complained, and the resident stated that the night nurse made fun of him but he did not want to say anything because he feared retaliation. The resident’s clinical record lacked evidence that the allegation was followed up on, resolved, or that psychosocial monitoring or other actions were completed related to the abuse allegation. The facility was unable to provide an investigation dated before the survey that addressed the allegation. During the survey, the resident stated that the LPN and the CNA made fun of his body and speech, including comments about his abdomen and accent, and that this made him feel sad and angry. He also stated that the LPN and the CNA had made fun of him, but that since the CNA no longer worked there, the LPN had been on good behavior. Facility staff stated they had not reviewed the resident council minutes before the survey and acknowledged that resident concerns should have been followed up. The facility’s internal investigation noted the resident council allegation and also documented that the CNA had yelled at residents, while current administration stated it was not aware of the issues in the resident council minutes.
Failure to Report Resident Abuse Allegation
Penalty
Summary
The facility failed to ensure staff reported Resident 9’s allegation of verbal and mental abuse to the administrator and State Agency as required. Resident council minutes documented that some residents feared nurses and nurse aides would treat them worse if they complained, and Resident 9 stated that the night nurse, LN K, made fun of him, but he did not want to say anything because he thought staff would retaliate. The resident’s clinical record did not show that this allegation was followed up, resolved, or monitored psychosocially, and the facility could not provide evidence that the allegation had been reported to the State Agency or that an investigation had been completed before the survey. During the survey, the facility’s internal investigation noted that the current administration had not been aware of the resident council concerns until surveyors identified them. The investigation also referenced a separate incident in which CNA QQ yelled at a couple of residents. Facility staff stated they had not reviewed the past resident council minutes and should have followed up on resident concerns. The facility policy in effect stated that all allegations of abuse, neglect, misappropriation of resident property, or exploitation were to be reported immediately to the Administrator and reported outside the facility to the appropriate State or Federal agencies within applicable timeframes.
Failure to Investigate Abuse Allegation and Protect Resident
Penalty
Summary
The facility failed to investigate an allegation that Licensed Nurse K verbally and mentally abused Resident 9 and failed to implement protective measures after the allegation was identified in resident council minutes. The November 2025 resident council minutes documented that some residents feared nurses and nurse aides would treat them worse if they complained, and Resident 9 stated that the night nurse, LN K, made fun of him but he did not want to say anything because he thought staff would retaliate. Review of Resident 9’s clinical record showed no evidence that the allegation was followed up, no evidence of resolution, no psychosocial monitoring, and no further actions related to the abuse allegation. The facility was unable to provide an investigation dated before the survey that addressed the allegation. During the survey, the facility’s internal investigation documented that surveyors identified the resident council note about LN K making fun of Resident 9, and that the current administration had not been aware of the issue until the survey. The investigation also noted a separate incident in which CNA QQ yelled at residents, and facility staff stated that the department heads should have read the resident council minutes and followed up. Interviews showed that the facility had only just begun investigating the allegation when surveyors asked about it, and staff acknowledged they had not reviewed the resident council minutes earlier. The facility policy stated that allegations of abuse required immediate protection of residents from physical and psychosocial harm, including staffing or room changes if necessary, but those steps were not documented before the survey.
Missing Annual Performance Evaluations for CNA and CMA Staff
Penalty
Summary
The facility failed to ensure yearly performance evaluations were completed for four of four CNA and one CMA staff reviewed. Record review showed CNA MM, hired 06/05/24, had no yearly performance evaluation available upon request; CNA NN, hired 02/05/25, had no yearly performance evaluation available upon request; CNA 00, hired 06/03/21, had a yearly performance evaluation that lacked a date and signature; and CMA S, hired 03/27/25, had no yearly performance evaluation available upon request. On 05/14/26 at 01:23 PM, Administrative Staff B stated that each department head was responsible for ensuring yearly evaluations were completed. The facility was unable to provide a policy related to yearly performance evaluation when requested on 05/14/26.
Infection Control Failures With Respiratory Equipment, Linen Handling, and Hand Hygiene
Penalty
Summary
The facility failed to implement adequate infection control practices when staff did not store respiratory equipment in a sanitary manner and did not maintain clean and dirty items appropriately. During the initial walk-through, R13’s nebulizer mask was found laying on the windowsill and was not stored in a sanitary container. R86’s wheelchair had a portable oxygen tank, and her nasal cannula tubing was laying in the seat of the wheelchair rather than being stored in a sanitary container. The facility’s oxygen equipment policy stated humidifiers, tubing, masks, and cannulas were to be maintained in a clean and sanitary manner and discarded after use by a resident. The facility also failed to maintain hand hygiene and proper separation of clean and dirty items. A wet brief was found open and wet with urine in the trash can next to R28’s bed, clean linen was observed on a PPE cart directly on top of a box of opened gloves, and soiled linen and incontinent products were placed into plastic bags after being picked up from the floor. CNA O later placed a bag of soiled linen and a bag of trash into the soiled utility room, exited without performing hand hygiene, entered the clean linen room, removed clean sheets, and walked down the hallway without hand hygiene. In R9’s room, LN I placed a blood glucose monitor on the bottom bed rail without a clean barrier, obtained the blood glucose reading, and then laid the monitor back on the bed rail.
Failure to Verify Required Communication Training for Agency Staff
Penalty
Summary
The facility failed to ensure agency staff received the required communication training. During record review on 05/14/26, documentation could not be provided showing that agency CNA P, CNA Q, and LN K had completed the facility's communication training. During an interview later that day, Administrative Staff B stated she was responsible for scheduling agency staff and that the facility expected the agency to have already provided the required training and in-services to its staff before they were scheduled at the facility. The facility was also unable to provide a policy related to staff required in-services when requested.
Failure to Verify Agency Staff Resident Rights Training
Penalty
Summary
The facility failed to ensure agency staff received the required resident rights training. During record review on 05/14/26, documentation could not be provided showing that agency CNA P, CNA Q, and LN K had completed resident rights training. During an interview later that day, Administrative Staff B stated she was responsible for scheduling agency staff and that the facility expected the agency to have already provided the required training and in-services to its staff before they were scheduled at the facility. The facility was also unable to provide a policy related to staff required in-services when requested.
Failure to Verify Required Behavioral Health Training for Agency CNA
Penalty
Summary
The facility failed to ensure agency staff received the required behavioral health training consistent with the facility assessment. During record review on 05/14/26, the facility was unable to provide documentation that agency CNA P had completed behavioral health training. During an interview the same day, Administrative Staff B stated she was responsible for scheduling agency staff and that the facility expected the agency to have provided the required training and in-services to its staff before they were scheduled at the facility. The facility was also unable to provide a policy related to required staff in-services when requested.
Unsafe Walkway, Ants in Dining Area, and Broken Resident Room Light
Penalty
Summary
The facility failed to provide a safe and clean homelike environment when the walkway and sidewalk into the building had several missing red tiles/bricks with raised dots at the entrance. The report also documented ants crawling across a table in the east dining room, and dietary staff stated the ants had already been reported. Maintenance later stated pest control had come out the previous day after the ants were reported and that a work order had been placed for the walkway brick repair. The facility also failed to ensure adequate lighting in Resident 19's room because the ceiling light above the resident's bed was not working properly. Resident 19 stated the light had not worked since admission. Maintenance stated the facility used a TELS system and a dry-erase board for maintenance requests, but they had not been informed about the light above the resident's bed not working and said staff would get it repaired.
Failure to Provide Consistent Bathing Assistance
Penalty
Summary
The facility failed to ensure dependent residents received necessary ADL bathing care. R47 had diagnoses including quadriplegia and central cord syndrome, was cognitively intact, used a wheelchair, and was dependent on staff for showering and bathing. His care plan directed staff to assist with bathing and allow him time to answer questions and express preferences, but it did not include direction on his preferred bathing day or time. The EMR showed scheduled bathing times on Wednesday and Saturday evenings, yet the documentation included multiple refusals, several entries marked NA, and no shower or bath given in April 2026. On observation, R47 was found in bed with a dirty appearance to his hair and beard, and later a CNA gathered bathing supplies and stated she was going to give him a bath because he agreed that morning. R6 had diagnoses including hemiparesis/hemiplegia after intracerebral hemorrhage, vascular dementia, contractures, cognitive communication deficit, and Parkinson’s disease. His MDS showed severely impaired cognition, and he was dependent for all self-care and mobility except eating. His care plan noted that he sometimes refused baths or showers and that staff should provide clear, concise instructions and offer choices in his daily routine. The EMR listed preferred bathing days as Wednesday and Saturday evenings, but the bathing documentation showed only two showers in the record reviewed, with the last scanned bath sheet dated 12/10/25. When observed, R6 was sitting in his Broda chair with gray whiskers, matted hair, and brown substances under his fingernails. R77 had diagnoses including respiratory failure, CHF, sleep apnea, cognitive communication deficit, and pneumonia. Her MDS showed intact cognition, with impairment of the extremities on one side of the upper body and both lower extremities, and she was dependent for oral hygiene and needed substantial to maximal assistance with bathing and toileting. Her care plan directed staff to wash, rinse, and dry the perineum after incontinence episodes and to assist with bathing and shower transfers. The EMR listed preferred shower days as Monday and Wednesday mornings, but the bathing record showed sponge baths and only one shower in the period reviewed, with one bath sheet documented. On observation, R77 had brown substance under her fingernails, and she stated she had not had a scheduled shower day, had not had a shower since coming to the facility, and wanted a shower. Staff interviews reflected uncertainty about the bathing schedule and concerns about bathing coverage, while administration stated the expected process was for the CNA to give the shower and document it, and that NA should not be used for shower or bath documentation.
Medication Error Rate Exceeded Allowed Threshold
Penalty
Summary
The facility failed to ensure the medication error rate did not exceed five percent when seven of Resident 1’s 14 medications were administered outside the allowed 60 minutes before or 60 minutes after window. On 05/13/26 at 09:35 AM, a Certified Medication Aide was observed with Resident 1’s MAR open on a laptop at the medication cart and was seen popping medications from a bubble pack into a medication cup before entering the resident’s room and giving the medications to the resident, who took them without difficulty. An Administration History Report obtained on 05/14/26 showed that seven morning medications were given late on 05/13/26. These included ascorbic acid 500 mg, buspirone HCl 10 mg, hydralazine HCl 25 mg, pantoprazole sodium 40 mg, baclofen 15 mg, Systane ophthalmic solution 0.6%, and ipratropium bromide nasal solution 0.03%. The CMA stated he was running behind that day and trying to get residents’ medications given correctly and efficiently.
Pest Control Program Failed to Keep Dining Area Free of Ants
Penalty
Summary
The facility failed to keep the environment free from pests and to maintain an effective pest control program when ants were observed crawling across a table in the east dining room. During the observation, Dietary Staff BB stated she had reported the ants on the table to maintenance. Administrative Staff C stated pest control came monthly and as needed when pests were noted between visits, and that an order had been entered in TELS. Maintenance U stated he had been notified by a resident in the dining room and by staff about the ants the day before, and that pest control had been called and would come the next day to spray for ants in the dining room and check for other pests. Maintenance U also stated it was spring and ants were looking for food and could get inside the building. The facility's March 2026 Pest Control policy stated the facility was to provide an environment free of pests, have a pest contract for frequent treatment, allow additional visits when a problem was detected, and monitor the environment through staff.
Call Lights Not Kept Within Reach for Two Residents
Penalty
Summary
The facility failed to ensure that R6’s and R43’s call lights were within reach so they could call for staff assistance. R6 had diagnoses including hemiparesis/hemiplegia after an intracerebral hemorrhage, vascular dementia, contracture of the left forearm and hand, cognitive communication deficit, and Parkinson’s disease. His MDS documented severely impaired cognition, one-sided upper and lower body impairment, and dependence on staff for toileting and oral hygiene. His care plan noted he was provided a soft touch call light and later that brightly colored tape was to be placed on it to remind him to use it to get out of bed. During observation, R6 was in a Broda chair beside his bed while his soft touch call light was placed in the middle of the bed on one occasion and behind him on a bedside table on another, and he was unable to reach it; he was also observed yelling for help while unable to pull the blankets close enough to reach the call light. R43 had diagnoses including aphasia, a G-tube, and CVA, with severely impaired cognition, limited ROM on one side, and dependence on staff for all ADLs. Her care plan directed staff to ensure the call light was within reach and encourage her to use it as needed. During observation, R43 was lying in bed with the head of the bed only slightly elevated, her G-tube patent, and her call light attached to the bed with the cord and button hanging behind the bed, out of reach. Staff interviews confirmed that call lights should always be within residents’ reach, and an administrative nurse stated the same.
Failure to Complete Discharge Documentation and Ombudsman Notification
Penalty
Summary
The facility failed to ensure that a discharge summary was completed for Resident 83 and failed to provide a recapitulation of the resident’s stay at the facility. Resident 83’s EMR documented diagnoses of chronic pain and COPD. A nursing note dated 04/10/26 at 03:06 PM stated that the resident was to be discharged home with medications and all personal belongings, and that discharge instructions were reviewed with the resident, who voiced no concerns. During record review and staff interviews, Administrative Staff C stated on 05/13/26 at 09:25 AM that she was unable to locate a discharge summary for Resident 83. On 05/14/26 at 11:10 AM, Social Services X stated she had only sent the list of residents who had transferred to the hospital. On 05/14/26 at 02:51 PM, Administrative Nurse D stated social services would start the discharge process and open the discharge summary form in the resident’s EMR, and also stated the charge nurse on duty would complete the discharge summary at the time of discharge. The facility’s Admission, Transfer, and Discharge policy dated 03/03/26 stated that when the facility transferred or discharged a resident, the transfer or discharge would be documented in the resident’s medical record and appropriate information would be communicated to the receiving health care institution or provider. The facility also failed to notify the state ombudsman of the resident’s discharge from the facility.
Failure to Provide Individualized Activities and Redirection
Penalty
Summary
The facility failed to implement an activities program to support R6’s social needs through both individual and group activities and failed to provide one-on-one activity or diversions from his red activity bag when he remained in his room. R6 had diagnoses including hemiparesis/hemiplegia following a nontraumatic intracerebral hemorrhage, vascular dementia, contracture of the left forearm, left hand cognitive communication deficit, and Parkinson’s disease. His Quarterly MDS documented a BIMS score of 6, indicating severely impaired cognition, and also documented impairment on one side of his upper and lower body, set up or clean up assistance with eating, and dependence on staff for toileting and oral hygiene. R6’s CAA documented that he was dependent on staff for all self-care and mobility tasks except eating. His care plan stated he was dependent on staff assistance with activity participation due to cognitive impairment and left side hemiplegia, that staff were to invite him to scheduled activities, that his preferred activities included happy hour, ice cream socials, baking buddies, bingo, and going outside, and that he needed one-to-one bedside visits and activities in his room if he was unable to attend out-of-room events. The care plan also stated he was to be given as many choices as possible about care and activities. A red activity bag was hanging in his room with a sign stating to give him something from the bag if he needed redirection. Survey observations showed that on multiple occasions R6 sat alone in the dining room for breakfast and lunch, was pushed back to his room, and had his Broda chair backed next to his bed without being provided one-to-one time or anything from his red activities bag. Activities Director Z stated R6 was very disruptive in activities, had not been to many activities, and that she had not had a lot of time to do one-to-one activities because it was just her. CNA N stated she knew R6 had a red bag of things he could be given to keep him busy, and LN J stated any staff can take a resident to activities and that staff should make sure a resident had something from the activity bag. Administrative Nurse D stated staff should be interacting with all residents, that R6 should still be offered activities and interactions, and that staff should be giving him something from his red bag for distractions if he was not going out to activities.
Failure to Provide Ordered Pressure-Relieving Devices and Heel Protection
Penalty
Summary
The facility failed to provide adequate care and services to promote healing of pressure ulcers and to prevent new pressure injuries for multiple residents. R4 had diagnoses including diabetes mellitus, aphasia following a stroke, and stage 4 pressure ulcers to both heels. Her records showed severe cognitive impairment, dependence on staff for all ADLs, and risk for pressure injury. Her care plan and physician orders required pressure-relieving Prafo boots on both feet at all times, along with wound treatments for the heels and low air loss mattress use for skin integrity. During observation, R4 was found lying in bed with a boot on the right heel, but the left heel was resting directly on the mattress and the left boot was not in place as documented in the care plan. Staff interviews showed the CNA was responsible for applying boots and floating heels, and the nurse stated R4 should always have both boots on her heels and that staff on the hall were responsible for ensuring ordered care was provided. Administrative nursing staff stated that if a care plan required boots, both the CNA and LN should ensure they were on. R43 also had diagnoses including aphasia, a G-tube, and CVA, with severely impaired cognition and dependence on staff for all ADLs. Her care plan and physician orders required Prafo boots on both lower extremities at all times. During observation, R43 was lying in bed and both heels were resting directly on the mattress, with no Prafo boots in place. R53 had diagnoses including repeated falls, disorientation, diabetes mellitus, and multifocal motor neuropathy, with moderate cognitive impairment and risk for pressure ulcers. Although he was on a turning/repositioning program and had pressure-reducing devices ordered, observations showed his wheelchair lacked a cushion and anti-tip devices, and he reported that his buttocks hurt after sitting in the wheelchair.
Failure to Apply Left Hand Splint for Contracture Prevention
Penalty
Summary
The facility failed to provide care and services to maintain or improve range of motion when staff did not place Resident 6’s left hand splint for contracture prevention. Resident 6 had diagnoses including hemiparesis/hemiplegia following a nontraumatic intracerebral hemorrhage, vascular dementia, contracture of the left forearm and left hand, cognitive communication deficit, and Parkinson’s disease. The Quarterly MDS documented a BIMS score of 6, indicating severely impaired cognition, and showed that Resident 6 had impairment on one side of the upper and lower body and was dependent on staff for toileting and oral hygiene, with set up or clean up assistance needed for eating. The care plan stated staff may offer a resting hand splint as tolerated for contracture prevention to the left hand, and the physician’s order directed that the splint may be offered every shift. The TAR from 05/01/26 through 05/14/26 documented “N” for the splint, and the record lacked documentation that Resident 6 refused the splint. During observations on 05/12/26 and 05/13/26, Resident 6 was seated in a Broda chair with his left hand uncovered and his fingers curled down into the palm of his hand. A sign in the room instructed staff to help put on the left hand brace every morning and remove it before bed. Staff interviews showed CNA N did not know who was responsible for applying the brace and stated she had never applied it, while LN J stated it was the CNA’s duty to apply the splint and the nurse should check that it was on. Administrative Nurse D stated the CNA was responsible for applying the splint and the nurse should double check that it was on the resident.
Unsafe oxygen storage and missing fall interventions
Penalty
Summary
The facility failed to secure pressurized supplemental oxygen tanks in a safe, locked area and failed to keep oxygen cylinders properly stored. During an initial walkthrough, an unsecured oxygen storage room was found on the west hallway with 34 pressurized supplemental oxygen cylinder tanks stored in floor racks behind a key-locked entry door. An oxygen cylinder was also observed sitting directly on the floor in the corner of a resident room, with the oxygen cylinder cart present in the room but the cylinder not placed on it. The facility also failed to ensure fall interventions were in place for a resident with a history of repeated falls and moderately impaired cognition. The resident’s record documented diagnoses including repeated falls, disorientation, diabetes mellitus, need for assistance with personal care, and multifocal motor neuropathy. His MDS showed a BIMS score of 8, supervision to touch assistance for some transfers, and independence for toilet transfers. His falls CAA identified prior non-injury falls and risk factors including diabetes, decline in cognition, incontinence, and need for assistance with cares. His care plan included orienting him to the call light and applying anti-tippers to his wheelchair. At observation, the resident’s wheelchair was next to his bed with a Dycem on the seat, but the wheelchair lacked a cushion and anti-tip devices on the back. The resident stated his buttocks hurt after sitting in the wheelchair, and later he was observed propelling the wheelchair without the cushion or anti-tip devices in place. Another resident with diagnoses including HTN, contracture, muscle weakness, and lupus was found on the floor by a CNA after a documented fall. That resident’s care plan included use of a slide board for transfers, keeping the call light within reach, and placing bolsters on the bed, but during observation the bed was in a high position and the call light was wrapped around the side rail and dangling out of reach. The resident stated he could not reach or find the call light and did not like the bed in a high position.
Improper Positioning During G-Tube Feeding
Penalty
Summary
The facility failed to ensure Resident 43 received appropriate treatment and services for enteral nutrition when staff did not position the resident to prevent potential aspiration while the gastrostomy tube was infusing. Resident 43’s EMR documented diagnoses of aphasia, a gastrostomy tube, and CVA. The admission MDS documented severely impaired cognition, limited ROM on one side of the body, dependence on staff for all ADLs, coughing or choking during meals or when swallowing medications, and receipt of 51 percent or more of total calories through tube feeding. Resident 43’s Feeding Tube Care Area Assessment documented a history of CVA and dependence on staff assistance for ADLs and gastrostomy nutrition. The care plan directed staff to elevate the head of the bed at least 30 to 45 degrees at all times during feeding, and the physician order required head-of-bed elevation at least 30 to 45 degrees at all times during feeding and for 1 hour after. During observation, Resident 43 was lying in bed with the head of the bed only slightly elevated, less than 30 to 45 degrees, while the gastrostomy was infusing. The resident’s call light was attached to the bed with the cord and button hanging behind the bed, and both heels were resting directly on the mattress. An Administrative Nurse stated the head of the bed should be elevated at least 30 to 45 degrees at all times.
PICC Line Removal Not Timely or Fully Documented
Penalty
Summary
The facility failed to provide services consistent with the standards of care related to Resident 4’s PICC line when the physician’s order for in-facility removal after completion of IV antibiotic therapy was not followed for three days. Resident 4 had diagnoses including anxiety, diabetes mellitus, aphasia following cerebral infarction, and pressure ulcers to both heels, and the MDS documented severely impaired cognition with a BIMS score of zero, dependence on staff for all ADLs, impairment of both upper and lower extremities, and receipt of IV medications during the observation period. The care plan did not address the PICC line or associated care. The record showed orders for PICC dressing changes, cap changes, and daily saline flushes, and documentation stated to continue Daptomycin/Cerftiax through 05/08/26 and then remove the PICC line. Nursing notes documented the PICC line was removed on 05/12/26 and again on 05/13/26, but the chart lacked a physician order to remove the line and lacked documentation confirming the full removal of the line, including the tip. The record also lacked documentation of inspection of the PICC line after removal to ensure it was fully removed without complications. Administrative nurses stated the order had been sent to department heads, nursing had not done anything with it, and the facility should document the removal and any monitoring or complications.
Respiratory Equipment Not Stored in a Sanitary Manner
Penalty
Summary
The facility failed to provide adequate respiratory care and services for a resident with respiratory failure, CHF, sleep apnea, cognitive communication deficit, and pneumonia. The resident’s record showed she required oxygen therapy, had shortness of breath at rest, and was dependent on staff for oral hygiene with substantial to maximal assistance needed for bathing and toileting. Her care plan included BiPAP use at night and PRN, oxygen as needed, and monitoring for changes in orientation, restlessness, anxiety, and air hunger. The resident’s orders included continuous oxygen at 4 liters per minute via nasal cannula, weekly oxygen equipment maintenance, and daily rinsing of the BiPAP mask. Nursing notes documented an episode in which the resident developed shortness of breath, low oxygen saturations, chest pain, and was transferred to the ED after oxygen levels could not be maintained above 91 percent. Additional nursing notes stated that the BiPAP mask was not seen in the resident’s room while she was on oxygen via nasal cannula. During observation, the resident’s BiPAP mask was found on the floor next to the bedside table and her nasal cannula was on the floor next to the portable oxygen tank. On another observation, the BiPAP mask was draped over the machine and the nasal cannula was wrapped around the oxygen tank. The resident stated she did not wear the BiPAP every night and said staff did not know the settings or could not find the mask, so she would use only the nasal cannula at night. Staff interviews confirmed respiratory equipment should be placed in a dated bag when not in use and that it was the nurse on duty’s responsibility to ensure the mask and tubing were not placed on the floor.
Failure to Provide Effective Pain Management
Penalty
Summary
The facility failed to provide effective pain management, including ongoing assessment and monitoring for effectiveness of pain relief, for a resident with diagnoses of hypertension, contracture of muscle, muscle weakness, lupus, and rheumatoid arthritis of both hands. The resident’s care plan identified pain aggravated by prolonged activity and directed staff to reposition for comfort, administer pain medication and an antidepressant for chronic pain, monitor complaints of pain or requests for treatment, notify physicians if interventions were unsuccessful, and complete pain assessments every shift. Physician orders included duloxetine daily for chronic pain and oxycodone every six hours as needed for breakthrough pain. On 05/12/26, the resident was documented with a pain level of 10 and excruciating pain and was given oxycodone. At the same time, the resident was observed yelling for help and stating he was in pain and had been yelling for pain medication. He stated he could not find his call light, which was found wrapped around the right-hand side rail and dangling where he could not reach it. Another resident reported hearing him yell for help often and said nursing took a long time to come to his room. Staff interviews confirmed that residents should not have to find nursing staff for assistance and that all staff were responsible for monitoring the resident’s pain, yet the record and observations showed the resident was relying on others to locate staff when he needed pain assistance.
Failure to Provide Dementia-Related 1:1 Activities and Support
Penalty
Summary
The facility failed to provide dementia-related care and services for a resident with diagnoses of dementia, anxiety, major depressive disorder, and Alzheimer’s disease, whose MDS documented severely impaired cognition with a BIMS score of four and dependence on staff for mobility. The resident’s CAA documented memory problems and impaired decision-making ability. His care plan directed staff to identify themselves, reduce distractions, orient him as needed, explain care and procedures, and provide psychosocial support. It also directed staff to provide a 1:1 program with in-room activities, supplies, conversation, and comfort, noting that because he was legally blind he did not do arts, crafts, drawing, or games, but did like rock and roll music and cowboy movies and would benefit from in-room visits two times a week. Review of the resident’s documentation from 03/01/26 through 05/12/26 showed only one activity documented on 04/04/26. Observation on 05/12/26 found the resident reclined in a Broda chair next to the nurse station with his eyes closed. On 05/13/26 he was observed reclined in a Broda chair in the dining room alone, then later by the nurse station in a Broda chair, and then returned to his room where he was placed reclined in the Broda chair next to his bed with the blinds shut and the room lights off. The Activities Director stated she documented activities in the EMR and that the resident would benefit from 1:1 activity, but she had not had much time to do one-to-one activities because she was the only one. A CNA stated the resident did not attend activities and was unsure who would do 1:1 activities. An LN stated any staff could take a resident to or provide activities, and the Administrative Nurse stated all staff should interact with residents and that residents with dementia should be offered activities or provided 1:1 interaction.
Unlocked Medication Cart Left Unattended
Penalty
Summary
The facility failed to store medication and biologicals adequately when staff left medication carts unlocked and unattended. On 05/13/26 at 08:15 AM, the medication aide cart on the northeast hall was left unlocked and unattended when Certified Medication Aide R stepped away from the cart to go into a resident's room. Later that day at 02:07 PM, the northeast hall medication cart was again left unlocked while it was being used by CMA R to clean up the southeast hall medication cart. Administrative Nurse E then walked up to the cart and locked it. CMA R stated he only stepped away briefly but should have locked the cart when he left it, and LN H stated the medication cart should be locked anytime staff walk away from it or when it is not being used. Administrative Nurse E also stated medication carts should always be locked when staff walk away from them, and noted this cart did not contain narcotic medications. The facility's Medication Access and Storage policy dated October 2025 stated all drugs and biologicals are to be stored in locked compartments and that medication carts are locked when the person administering medications steps away from the cart.
Failure to Document Vaccine Offerings and Declinations
Penalty
Summary
The facility failed to offer and administer, or obtain an informed declination for, the Pneumococcal Conjugate Vaccine (PCV20) and influenza vaccine for R3. Review of R3's clinical record showed refusals for both PCV20 and influenza vaccines, but the record did not contain documentation that either vaccine was offered or declined, and it also lacked documentation of a historical administration or a physician-documented contraindication. During interview, an Administrative Nurse stated she was unable to find R3's declination, and another Administrative Nurse stated the admitting nurse was responsible for ensuring the resident or family signed a consent or declination for immunizations, while also noting that the infection preventionist should be following up on immunization consent or declination. The facility did not provide an immunization policy when requested.
Daily Nurse Staffing Information Not Posted or Complete
Penalty
Summary
The facility failed to ensure that daily nurse staffing data was posted and failed to ensure that the daily posted nursing staffing included the required information. On 05/12/26 at 08:01 AM, review of the daily posted nursing staffing sheet showed a date of 05/08/26, and review of posted staffing sheets from 05/11/24 to 05/11/26 showed that the form used from 05/01/26 to 05/07/26 did not include a daily census on the posted sheets. On 05/13/26 at 08:06 AM, Administrative Nurse D stated Administrative Staff B was responsible for ensuring the daily posted nursing staff sheets were posted, and that on weekends the receptionist would post the daily nursing sheets provided by Administrative Staff B; Administrative Nurse D also stated the daily census information should be included. The facility's Posted Direct Care Daily Staffing Numbers policy, last revised 08/2022, stated the facility would post nurse staffing data daily for each shift, including the number of nursing personnel responsible for providing direct care to residents.
Failure to Monitor and Adjust Enteral Nutrition Leads to Significant Weight Loss
Penalty
Summary
The facility failed to consistently monitor the weight of a resident, identified as R27, who was receiving enteral nutrition through a PEG tube due to severe cognitive impairment and medical conditions such as aphasia, dysphagia, and hemiplegia. Upon admission, R27 weighed 155 pounds and was dependent on staff for all activities of daily living. Despite being at risk for complications related to her PEG tube, the facility did not trigger a Nutrition Care Area Assessment upon her admission, and her care plan did not adequately address her nutritional needs. R27 experienced a significant, unplanned weight loss of 11.74% over 37 days, dropping to 136.8 pounds. The facility's records showed a lack of consistent weight monitoring and documentation, with no follow-up from the medical provider or registered dietician despite the resident's continued weight loss. The facility's policy required weekly weigh-ins for at-risk residents, but this was not adhered to, and the resident's nutritional regimen was not adjusted in response to the weight loss. Interviews with staff revealed that there was a breakdown in communication and documentation regarding R27's nutritional status and weight loss. The registered dietician was on maternity leave, and a temporary dietician was not adequately informed of the resident's condition. The facility's failure to monitor and adjust R27's enteral nutrition regimen in a timely manner led to the significant weight loss, highlighting deficiencies in the facility's nutritional management practices.
Lack of Communication Training for Agency Staff
Penalty
Summary
The facility failed to ensure that agency direct care staff received the required communication training, which placed residents at risk for impaired care and decreased quality of life. During a review of the training records for agency CNAs, it was found that the credentialing files for three CNAs lacked evidence of completed communication training. Administrative Staff A acknowledged that during orientation, the curriculum covered various topics such as timekeeping, meal breaks, smoking policy, cell phone and social media use, dress code, dietary services, fall prevention, infection control, abuse, customer service, and information related to protected health information and electronic medical records. However, it was assumed that the staffing agency ensured the completion of required in-services for nurse aides, which was not the case. Administrative Staff A stated that communication, resident rights, and dementia training would be added to the curriculum for agency staff.
Deficiency in Resident Rights Training for Agency Staff
Penalty
Summary
The facility, with a census of 66 residents, failed to ensure that agency direct care staff received the required training on resident rights. This deficiency was identified through a review of the training records for agency CNAs P, Q, and LL, which revealed a lack of evidence that these staff members completed the necessary resident rights training. During an interview, Administrative Staff A acknowledged that the orientation for agency employees covered various topics, including timekeeping, meal breaks, smoking policy, cell phone and social media use, dress code, dietary services, fall prevention, infection control, abuse, customer service, and information related to protected health information and electronic medical records. However, it was assumed that the staffing agency ensured the completion of required in-services for nurse aides, which was not the case. This oversight placed residents at risk for impaired care and decreased quality of life.
Deficiency in Dementia Training for Agency CNAs
Penalty
Summary
The facility failed to ensure that agency direct care staff received the required dementia training for nurse aides, which placed residents at risk for impaired care and decreased quality of life. During a review of the training records for agency CNAs, it was found that the credentialing files for three CNAs lacked evidence of completed in-service training. Administrative Staff A acknowledged that the orientation for agency employees covered various topics, but assumed that the staffing agency ensured the completion of required in-services for nurse aides. This oversight resulted in the absence of necessary training in communication, resident rights, and dementia care for agency staff.
Failure to Maintain a Safe Environment and Follow Fall Prevention Interventions
Penalty
Summary
The facility failed to maintain a safe environment free from potential hazards for its residents, particularly those who are cognitively impaired and independently mobile. During an inspection, it was observed that cleaning chemicals and Microkill wipes were left accessible in the main lobby's kitchenette, posing a risk to residents. Additionally, a pressurized carbon dioxide canister was found unsecured under a sink, and an oxygen storage room was left unlocked with several pressurized canisters inside. Furthermore, a large leak in the west dining hall was covered with soiled wet towels without a 'Wet Floor' sign, creating a slip hazard. The facility also failed to follow fall prevention interventions for two residents, R29 and R58. R29, who has moderate cognitive impairment and is at risk for falls, was found with a low air-loss mattress that was supposed to be discontinued due to safety concerns. Despite the care plan indicating the removal of this mattress, it remained in place, and staff were unable to verify if it was supposed to be there. Similarly, R58, who requires two-person assistance for transfers due to weakness, experienced a fall during a shower transfer when only one staff member was assisting him. This incident highlights the failure to adhere to the care plan interventions designed to prevent falls. Additionally, the facility did not ensure R6's room was free from physical hazards. R6, who is legally blind and has multiple medical conditions, had an unsecured oxygen canister left in his room. The canister was not in a holder or secured, contrary to the facility's policy on oxygen handling and storage. This oversight placed R6 at risk for injuries, as unsecured oxygen tanks can pose significant hazards. The facility's failure to secure the oxygen canister and adhere to its own policies contributed to the unsafe environment.
Failure to Secure Medication and Treatment Carts
Penalty
Summary
The facility failed to secure its medication and treatment carts, which placed residents at risk for unnecessary medication and administration errors. During an inspection on the East Hall nursing station, an unlocked skin treatment cart was found containing assorted medicated lotions with warnings to avoid ingestion and contact poison control. Additionally, at the [NAME] Hall station, an unsecured medication cart was observed with pill packs of Cefdinir and Junuvia left on top of the cart. These medications were not secured, and the cart stored both stock and prescription medications for residents in the [NAME] Hall. Licensed Nurse J verified the unsecured medications and carts, acknowledging that they should be locked when unsupervised and that medication should never be left unattended. Administrative Nurse D confirmed that the facility's policy required medication carts to be locked when not in use or supervised. The facility's Medication Access and Storage policy indicated that all medications and biologicals should be stored safely, following the manufacturer's storage recommendations, and properly labeled with expiration dates. The failure to adhere to these protocols resulted in the deficiency noted in the report.
Infection Control Deficiencies in Handling Laundry and Hand Hygiene
Penalty
Summary
The facility failed to adhere to sanitary infection control standards, which placed residents at risk for infectious diseases. Observations revealed multiple instances of improper handling of soiled laundry, such as soiled towels and bed linens being placed on the floor in various locations, including a kitchenette and resident rooms. Additionally, used personal protective equipment (PPE) was found discarded improperly, such as a soiled glove and broken facemask left on an Enhanced Barrier Precautions (EBP) cart, and used PPE on the floor of a resident's room. These actions indicate a lack of compliance with infection control protocols regarding the proper disposal of contaminated materials. Further deficiencies were noted in the administration of medications and hand hygiene practices. Certified Medication Aides (CMAs) failed to perform hand hygiene during medication preparation and administration, increasing the risk of contamination. A Certified Nurse's Aide (CNA) was observed not performing hand hygiene between glove changes and after providing personal care to a resident, despite acknowledging the importance of hand hygiene. Interviews with staff, including a Licensed Nurse and an Administrative Nurse, confirmed that hand hygiene should be performed frequently and that soiled laundry should not be placed on the floor. The facility's Infection Control and Surveillance policy, revised in October 2023, mandates routine infection control training, yet staff reported a lack of recent education on hand hygiene practices.
Failure to Provide Wheelchair Pedals for Resident
Penalty
Summary
The facility failed to provide a resident, identified as R39, with foot pedals for her wheelchair, which left her vulnerable to possible injury. R39 has a complex medical history, including dysarthria, a pacemaker, transient ischemic attack, diabetes mellitus, hemiparesis/hemiplegia, difficulty in walking, cerebral infarction, depression, and cerebrovascular accident. Her cognitive function is moderately impaired, as indicated by a BIMS score of eight, and she is dependent on staff for certain activities, such as putting on and taking off footwear. The care plan for R39 notes a contracture of her right upper and lower extremity, which further complicates her mobility. On a specific morning, R39 was observed rolling herself to breakfast using her left hand, without wearing her foot/ankle brace, and her right foot hit the floor twice while being propelled by a CNA. Interviews with staff, including a CNA, a Licensed Nurse, and an Administrative Nurse, confirmed that wheelchair pedals should have been provided to prevent injury when staff were pushing R39. The facility's policy on accommodating needs states that residents have the right to receive services with reasonable accommodation of individual needs, which was not adhered to in this instance.
Resident-to-Resident Abuse Incident
Penalty
Summary
The facility failed to protect residents from abuse when a resident, identified as R31, threw hot coffee on another resident, R40. R31, who has a history of hemiplegia, diabetes, hypertension, and peripheral vascular disease, was documented to have intact cognition and was independent in his functional abilities, using a motorized wheelchair for mobility. The incident occurred in the dining room when R31 became upset over a seating disagreement with R40, leading to R31 throwing coffee on R40's abdomen and thighs. R40 was assessed by a licensed nurse, who noted wet clothing but no immediate injury, although tiny raised areas were observed on R40's thigh the following day. The facility's investigation revealed that R31 had a history of becoming upset if he felt his prayer group time was impeded upon, and staff were instructed to approach him calmly and redirect him if necessary. However, during the incident, R31 expressed that the coffee spill was accidental, although he later made a comment suggesting intentionality. The facility's policy on abuse prevention emphasizes the right of residents to be free from abuse and the importance of staff intervention to protect residents' rights and safety. Despite this, no immediate further action was taken with R31 following the incident, as it was believed he posed no further threat. Interviews with staff indicated that the incident was reported immediately, but there was a lack of immediate intervention to prevent further harm. The facility's policy requires oversight and monitoring to prevent abuse, yet the actions taken were insufficient to ensure the safety and well-being of all residents. The failure to implement appropriate interventions and monitor residents with behaviors that might lead to conflict resulted in a deficiency in protecting residents from abuse.
Failure to Investigate and Prevent Resident-to-Resident Altercation
Penalty
Summary
The facility failed to fully investigate and implement interventions following a resident-to-resident altercation, where one resident threw hot coffee on another. The incident involved a resident with intact cognition and a history of hemiplegia, diabetes, hypertension, and peripheral vascular disease, who used a motorized wheelchair for mobility. This resident became upset when another resident did not move from a preferred spot in the dining room, leading to the altercation. Despite the incident, the facility did not take further action to address the behavior of the resident who threw the coffee. The facility's investigation report documented that the incident was reported to administrative staff, and the affected resident was assessed for injuries, which were minimal. However, the facility did not implement any interventions to prevent further incidents or address the behavior of the resident who initiated the altercation. The staff involved did not witness the incident directly but were informed by other staff members. The resident who threw the coffee claimed it was an accident, and no further actions were taken by the facility to ensure the safety of other residents. The facility's policy on abuse prevention emphasizes the right of residents to be free from abuse and the importance of taking action to prevent such incidents. Despite this policy, the facility did not take adequate steps to investigate the incident thoroughly or implement measures to prevent future occurrences. This lack of action placed residents at risk of harm and did not align with the facility's stated policies on abuse prevention and resident safety.
Failure to Obtain STAT Labs and Notify Physician
Penalty
Summary
The facility failed to ensure that staff obtained physician-ordered labs for a resident, identified as R45, and did not notify the physician of the delay in obtaining these labs. R45 had diagnoses of hypertension, a urinary tract infection, and a compression fracture of the lumbar vertebra. The resident required partial assistance for functional abilities and was dependent on staff for toileting and bathing. On a specific date, R45 presented with an altered mental status and heavy sweating, prompting an order for immediate labs, including urinalysis, a complete metabolic panel, and a complete blood count with differential. However, the labs were not obtained in a timely manner, and there was no documentation of further monitoring of R45's condition from the time the labs were ordered until they were eventually reviewed. The nursing notes indicated that staff attempted to contact the lab company multiple times to request a STAT lab draw, but the labs were not collected until several days later. During this period, R45's condition was not adequately monitored or documented, and the physician was not informed of the delay in obtaining the lab results. When the lab results were finally reviewed, they showed abnormal findings, and an order for an antibiotic was placed. However, there was a lack of documentation regarding the resident's condition and any signs or symptoms from the time the labs were ordered until the results were reviewed. Interviews with facility staff revealed a lack of communication and follow-up regarding the delay in obtaining the STAT labs. A licensed nurse acknowledged that the resident had not been followed up on appropriately, and the administrative nurse admitted to being unaware of the delay and the lack of physician notification. The facility did not provide a policy regarding quality of care, and the failure to obtain the STAT labs as ordered resulted in a delay in care and treatment for R45's urinary tract infection.
Failure to Apply Leg Brace for Resident with Contractures
Penalty
Summary
The facility failed to ensure that a resident's leg/ankle brace was applied when she was out of bed, which was necessary to prevent the worsening of her contractures. The resident, identified as having multiple medical conditions including hemiparesis and a history of cerebrovascular accident, was dependent on staff for assistance with activities of daily living, including the application of her leg brace. Despite a physician's order for the brace to be applied every shift when the resident was out of bed, observations revealed that the brace was not applied, and the resident reported that the CNA did not know how to put it on. Interviews with facility staff, including a CNA, a licensed nurse, and an administrative nurse, confirmed that the brace should have been applied and that there were no documented refusals from the resident regarding the application of the brace. The facility's policy on contracture documentation emphasized the importance of providing appropriate treatment to prevent a decrease in range of motion. However, the failure to apply the brace as ordered placed the resident at risk for worsening contractures and decreased mobility.
Deficient Perineal Care and Hand Hygiene Practices
Penalty
Summary
The facility failed to provide the standard of care for a resident with a history of urinary tract infections (UTIs). The resident, who had multiple medical conditions including moderately impaired cognition, was dependent on staff for all toileting hygiene. During an observation, a Certified Nurse's Aide (CNA) did not perform proper hand hygiene while assisting the resident with toileting. The CNA did not wash hands between changing gloves after cleaning the resident's back and front peri areas, which is against the facility's procedure for perineal care. This lack of proper hand hygiene placed the resident at risk for further UTIs. Interviews with staff revealed that the CNA acknowledged the mistake and admitted that the facility had not provided hand hygiene education since her hiring. A Licensed Nurse confirmed that the CNA should have washed her hands when transitioning from cleaning the back to the front peri area. An Administrative Nurse also stated that staff had not received follow-up in-service training on hand hygiene, only initial check-offs at hiring. The facility's failure to ensure proper hand hygiene during perineal care was a deficiency that increased the resident's vulnerability to UTIs.
Failure to Communicate Dialysis Condition
Penalty
Summary
The facility failed to consistently communicate a resident's medical condition prior to and post-hemodialysis, which placed the resident at risk of potential adverse outcomes and physical complications related to dialysis. The resident, who had a history of diabetes mellitus, hypotension, end-stage renal disease requiring dialysis, peripheral vascular disease, hypertension, muscle weakness, repeated falls, cognitive communication deficit, difficulty in walking, unsteadiness on feet, and dysphagia, was not properly assessed before and after dialysis sessions on multiple dates. The resident's care plan required nursing staff to check the dialysis fistula daily, monitor for signs of infection, and obtain pre- and post-dialysis vitals, but these assessments were not consistently documented. The facility's process for handling dialysis communication sheets was inadequate, as evidenced by the lack of completed pre- and post-dialysis assessments in the resident's clinical record. Licensed Nurse G and Administrative Nurse D acknowledged issues with obtaining communication sheets from the dialysis center, which were supposed to be filled out and returned to the facility. Despite attempts to improve the process by sending sheets in a binder, the facility's policy to assist residents in maintaining homeostasis and ensuring ongoing communication with the dialysis center was not effectively implemented, leading to the deficiency.
Failure to Address Behavioral Health Needs
Penalty
Summary
The facility failed to adequately meet the behavioral health needs of Resident 46, who was diagnosed with metabolic encephalopathy, cognitive-communication disorder, and other conditions that contributed to her moderate cognitive impairment. The resident exhibited verbal and physically aggressive behaviors, which were documented in her Minimum Data Set (MDS) and Behavioral Symptoms Care Area Assessments (CAA). Despite these assessments indicating a need for interventions, the care plan lacked specific strategies to address her continued refusal or resistance to care. Throughout the report, multiple instances were noted where the resident displayed aggressive and verbally abusive behavior towards staff, including refusing medications and treatments. Progress notes in the Electronic Medical Records (EMR) repeatedly lacked documentation of non-pharmacological interventions being offered or attempted to calm the resident. Additionally, there was no evidence that the medical provider was notified of the resident's behaviors, which is a critical step in managing such situations. Interviews with staff, including a Certified Nurse Aide (CNA), a Licensed Nurse (LN), and an Administrative Nurse, revealed that while there were care-planned interventions and mandatory training for handling behaviors, these were not consistently documented or followed. The facility's Behavioral Health Services policy emphasized the need for non-pharmacological interventions, yet the failure to implement these effectively placed the resident at risk for continued behavioral episodes and unmet care needs.
Failure to Address Dementia-Related Behaviors in Resident
Penalty
Summary
The facility failed to identify a pattern of dementia-related behaviors for a resident, referred to as R29, and implement meaningful interventions to promote her quality of life. R29 had a medical diagnosis of dementia, cognitive communication deficit, insomnia, and dysphagia. Her Minimum Data Set (MDS) indicated moderate cognitive impairment and required substantial assistance with daily activities. Despite having a care plan that noted her history of behaviors such as verbal aggression and banging on things, the facility did not effectively address her behaviors during mealtimes, which included throwing food, spitting food down her shirt, and pouring hot food on herself, resulting in a burn injury. Interviews with staff revealed that while they were aware of R29's behaviors and the need for supervision during meals, the facility did not have a specific policy related to dementia care. The facility's Behavioral Health Services policy emphasized the need for non-pharmacological interventions, but there was no evidence of a consistent approach to managing R29's behaviors. The lack of a structured plan and failure to monitor and intervene appropriately during mealtimes placed R29 at risk for preventable injuries and hindered her ability to maintain her highest practicable level of functioning.
Failure to Monitor Antihypertensive Medication Parameters
Penalty
Summary
The facility failed to ensure that staff followed physician-ordered parameters for monitoring a resident's antihypertensive medication, specifically metoprolol succinate. The resident, who had a history of congestive heart failure, myocardial infarction, diabetes mellitus, and chronic kidney disease, was at risk of unnecessary medication administration due to the lack of proper monitoring. The resident's care plan did not include specific directions for antihypertensive medications, and the medication administration records for April, May, and June 2024 showed a lack of blood pressure and pulse monitoring prior to administering the medication. Interviews with licensed nurses and administrative staff revealed that blood pressure and pulse should have been monitored before administering the medication, and the medication should have been held if the parameters were not met. However, the facility's policy on medication administration was not followed, as evidenced by the absence of monitoring records. This oversight placed the resident at risk for unnecessary medication administration and potential adverse side effects.
Failure to Post and Retain Daily Nurse Staffing Data
Penalty
Summary
The facility failed to ensure that nurse staffing data was posted daily with the required information and did not retain the posted daily staffing data as mandated. During an initial tour, it was observed that the staffing hours posted were outdated, and the facility census number was missing. Upon request, the facility could only provide staffing sheets from December 2023 onwards, with notable gaps in March and April 2024. Additionally, the sheets from May 2024 onwards lacked the daily facility census number. Interviews revealed that the responsibility for posting staffing hours was divided between front desk staff and the floor charge nurse on weekends. However, there was no specific policy in place for daily posted staffing hours, and the administrative staff was unaware of the omissions in the census number.
Failure to Provide Appropriate Wound Care for Resident with Diabetes and Amputations
Penalty
Summary
The facility failed to ensure that a resident with a history of diabetes mellitus (DM) and amputations received appropriate wound care and services to prevent complications from his medical conditions. The resident, who had severe cognitive impairment and required assistance with various activities, developed a wound on his left third toe that was not properly monitored or treated in a timely manner. Despite the resident's known risk factors, including DM and peripheral vascular disease (PVD), the facility did not follow its own policies for skin and wound monitoring and management. The resident's electronic medical record (EMR) documented that on 02/15/24, the resident's second toe on his left foot had moist, loose skin, which was cleaned and wrapped with gauze by a nurse. However, there was no evidence of follow-up monitoring, treatment orders, or physician notification until 02/21/24, when the resident was seen by a physician for a new open area on the third toe with a possible infection. The physician ordered antibiotics and wound care, but the delay in addressing the initial concern allowed the wound to worsen. By the time the resident was transferred to the hospital on 03/14/24, the wound had become severely infected, leading to the surgical removal of the third toe. Interviews with facility staff revealed inconsistencies in documentation and communication regarding the resident's wound care. The facility's failure to adhere to its policies and promptly address the resident's wound contributed to the deterioration of the resident's condition and the need for surgical intervention.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 838 citations issued within 25 miles in the last 12 months — including the 20 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Kansas City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Providence Place | 0.1 mi | ★★★★★ | 16 | 0 |
| Riverbend Post Acute Rehabilitation | 1.4 mi | — | 33 | 0 |
| Willow Point Rehabilitation And Nursing Center | 3.1 mi | ★★★★★ | 0 | 0 |
| Life Care Center Of Kansas City | 3.7 mi | ★★★★★ | 20 | 0 |
| Kaw River Care And Rehab | 5.2 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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 July 2026) and official state health department websites.