Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
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 Tonganoxie Terrace during CMS and state inspections, most recent first.
Failure to prevent facility-acquired pressure injuries: A resident with multiple existing wounds, limited mobility, and a Braden score indicating pressure injury risk developed new pressure injuries to the left middle toe and left lateral foot after admission. Records showed limited weekly skin observations, inconsistent wound documentation, and no pressure-relieving boots on admission despite the resident’s risk status and need for staff assistance with turning, repositioning, and weight shifting. The resident later had necrotic tissue, swelling, redness, drainage, and discomfort during wound care.
Failure to inform residents of the Ombudsman and State Agency contact information. Surveyors found the posters in the lobby/hallway, but resident council minutes did not document that the information had been shared. The Resident Council President said the council had not been informed, while Activity Staff said the information was discussed in council meetings but not recorded in the minutes. An admin staff member stated the information should be reviewed with the council at least annually.
The facility failed to inform the resident council where the state inspection results were located. The State Agency inspection book was in the front lobby, but resident council minutes did not document that location, and the council president stated the council had not been told. An activity staff member said survey and Ombudsman information was discussed in meetings but not recorded in the minutes, while an admin staff member stated the information should be reviewed with the council at least annually.
Facility failed to conduct and document a thorough facility-wide assessment to determine the resources needed to care for residents competently during routine operations, nights and weekends, and emergencies. An admin staff member reported being unable to locate the assessment when it was requested, even though she stated it had been completed and provided for the survey process along with a QAA committee review.
Medication storage deficiencies were identified when an open Lantus insulin pen in a nurse med cart was found without an open date, the med room refrigerator temperature log was not consistently completed, and an unlocked treatment cart contained expired naloxone plus other items labeled to keep out of reach of children. An LPN and an Administrative Nurse confirmed that insulin pens should be dated when opened, refrigerator temps should be checked and recorded daily, and the treatment cart should be locked when not in use.
Incomplete Hair Restraints During Food Prep: Dietary staff were observed preparing and serving meals without proper hair coverage. An DS with a beard and mustache did not wear a beard or facial cover while preparing drinks, another DS wore a beard cover but left the mustache uncovered while washing dishes and preparing salads, and a third DS entered the kitchen before putting on a hair net. A DS confirmed staff were expected to wear hairnets in the kitchen and that beard and mustache coverage was required.
QAA program failed to identify multiple facility-wide deficiencies involving resident rights, council communication, medication security, transfer notifications, care planning, bathing preferences, treatment documentation, pressure ulcer prevention, smoking assessment, infection control, dietary sanitation, facility assessment, and vaccination tracking. Findings also included misappropriation and diversion of morphine, unsecured meds and supplies, inconsistent med room temp documentation, improper dietary PPE, and failures related to EBP, legionella, and Prevnar 20 eligibility.
Infection control and water management failures were identified. The facility had no routine Legionella water checks or standing-water monitoring, and staff did not consistently use EBP gowns for residents with wounds or indwelling catheters. A nurse also carried a glucometer with a bloody strip down the hall before discarding it, and staff confirmed EBP signage and PPE were missing for several residents who required catheter care.
Failure to Document PCV20 Vaccine Offerings and Declinations: Record review showed five residents had no evidence of being offered the pneumococcal PCV20 vaccine, no signed consent or informed declination, and no physician-documented contraindication. An Administrative Nurse stated residents were offered pneumonia vaccines on admission and as indicated, but also verified the facility had not reviewed all residents for PCV20 eligibility and did not have a definitive system to track who was eligible or whether the vaccine had been offered or declined.
Failure to Provide Bed Hold Notices and Ombudsman Discharge Notifications: The facility did not provide written bed hold information to two residents or their representatives when they were transferred to the hospital, and it did not notify the LTCO of their facility-initiated discharges. One resident had multiple acute changes in condition, including fever, vomiting, low O2 saturation, altered mental status, and possible sepsis, while the other was sent out after retching with black/brown emesis. Records lacked bed hold signatures and discharge notification documentation.
A resident with significant mobility impairment and skin issues sustained a lower-extremity laceration during a transfer, but the care plan did not include interventions to prevent further injury and the wound cause was not documented in early notes. Another resident with nicotine dependency had documentation showing tobacco use, yet the smoking assessment said he did not smoke and no smoking care plan was in place despite facility policy requiring assessment of safe smoking ability and IDT review of the care plan.
Failure to provide required bathing assistance affected two residents who needed staff help with ADLs. One resident with vascular dementia and stroke sequelae required substantial to maximal assistance with showering, but bathing records showed missed and refused baths with no clear scheduled bathing dates documented. Another resident with DM, dementia, schizophrenia, an indwelling catheter, and dependence for bathing received only 8 showers out of 23 opportunities, and was observed with uncombed hair and several days of facial hair growth. The facility policy stated residents would be assisted with bathing according to schedule or request.
A resident with DM and cognitive impairment was transferred to the hospital with a blood glucose of 31, but the record lacked documentation that glucagon was given before transfer and lacked a progress note describing the event. The facility also failed to document nursing assessments and transfer-related notes for two other residents sent to the hospital, including one resident with a leg laceration requiring 17 sutures and another resident with penile pain and catheter issues. These omissions involved missing assessment and discharge documentation around hospital transfers.
Failure to Investigate an Unwitnessed Fall and Inaccurate Smoking Assessment: A resident with Parkinson’s disease, severe cognitive impairment, and high fall risk got out of bed after a CNA left the room and fell, striking the head on a roommate’s wheelchair and requiring hospital transfer for a forehead laceration with sutures. The EMR had no investigation notes identifying the cause of the fall or related interventions. In a separate issue, a resident with intact cognition and nicotine dependency was documented as not using tobacco on the MDS and smoking assessment, even though an encounter note stated he smoked half a pack per day; the care plan lacked smoking interventions.
Failure to account for controlled medications: A bottle of morphine 20 mg/ml concentrate belonging to a resident was unaccounted for during controlled substance reconciliation. Nurses reported counting narcotics at shift change and comparing them with the controlled drug administration record, but an administrative nurse verified the facility did not have a current system for monitoring narcotics or identifying potential diversion. The facility’s policy required narcotics to be signed out in the narcotics log and documented in the EMR when given.
A resident was not adequately prepared for a safe transfer or discharge, and the facility did not ensure that the process met the resident's needs and preferences, resulting in a deficiency related to transfer/discharge planning.
Missing Recapitulation of Stay in Discharge Documentation: The facility failed to include a recapitulation of stay in discharge documentation for three residents. Records showed one resident with depression, anxiety, and falls who self-discharged to a motel, one resident with sepsis and weakness who discharged home with HH, and one resident with depression, weakness, falls, and a hip contusion who planned discharge with HH. Although discharge instructions, social services notes, and nursing notes were present, the required concise summary of the resident’s stay and course of treatment was not documented.
A resident who was unable to perform activities of daily living did not receive the necessary care and assistance from staff, resulting in unmet care needs.
The facility failed to implement a water management program to prevent Legionella disease and did not ensure adequate infection control practices related to catheter care. Staff were unaware of the water management requirement, and multiple observations revealed improper handling of urinary catheters, including lack of privacy bags, inadequate disinfection, and poor hand hygiene. These deficiencies placed residents at increased risk for infection.
The facility failed to provide the required 12 hours of in-service education for CMAs and CNAs, placing residents at risk of receiving impaired care. This deficiency was confirmed by the Director of Nursing and was in violation of the facility's Competency of Nursing Staff policy.
The facility failed to ensure a safe environment and prevent accidents for residents. One resident burned his fingers while smoking due to inadequate safety assessments and preventive actions. Another resident with severe cognitive impairment was not re-evaluated for smoking safety for over two years. Additionally, the facility did not investigate or implement interventions to prevent falls and injuries for two residents, placing them at risk for further harm.
The Consultant Pharmacist failed to identify and report medications administered outside of physician-ordered parameters for several residents, including blood pressure medications and insulin. This oversight placed residents at risk for adverse side effects and unnecessary medications. Additionally, the CP did not address the inappropriate use of Seroquel for a resident with Alzheimer's.
The facility failed to properly label and manage insulin medications for three residents, leading to potential risks for ineffective medication administration. Insulin flex pens for two residents were not dated when opened, and an outdated insulin vial for another resident was not discarded. Administrative Nurse D confirmed that the facility's protocol requires nurses to date insulin when opened and discard it when outdated.
The facility failed to identify and investigate injuries of unknown origin in a resident with severe cognitive impairment and multiple medical conditions. The resident sustained two skin tears on separate occasions, but no investigation was conducted to determine the cause of the injuries, placing the resident at risk for ongoing abuse and/or neglect.
The facility failed to investigate two injuries of unknown origin for a resident with multiple health conditions, including dementia and congestive heart failure. Despite the facility's policy requiring investigation and reporting of all incidents, no investigation was conducted, placing the resident at risk for unidentified and ongoing abuse or neglect.
The facility failed to develop comprehensive care plans for three residents, leading to impaired care due to uncommunicated care needs. One resident's care plan lacked interventions for managing diabetes and preventing falls, another resident's care plan did not address behaviors and mood, and a third resident's care plan did not include smoking safety measures after a burn injury.
The facility failed to review and revise care plans for a resident with chronic pain and another with skin tears, leading to inadequate pain management and increased risk of injuries. The care plans lacked necessary interventions, and the facility did not investigate incidents or document alternative measures, resulting in uncommunicated care needs and impaired care.
The facility failed to provide necessary bathing services for three residents, leading to extended periods without showers and placing them at risk for impaired health. Despite being scheduled for regular showers, documentation showed multiple refusals without follow-up or reapproach by staff. Observations confirmed the residents' unkempt appearances, and staff verified the lack of adherence to the facility's policy on documenting refusals and follow-up actions.
The facility failed to provide appropriate catheter care and infection control practices for two residents, leading to increased risk of infection and other catheter-related complications. Observations revealed improper handling of urinary catheter bags, lack of privacy covers, and failure to disinfect catheter ports, contrary to the facility's policies.
The facility failed to provide non-medicinal pain relief measures and promote effective pain management for a resident with chronic pain. Despite receiving scheduled and PRN pain medications, the resident reported inadequate pain control. The care plan lacked direction for non-medication pain relief measures, and staff did not consistently offer or attempt alternative pain interventions. This placed the resident at risk for ongoing severe pain and impaired quality of life.
The facility failed to provide necessary dementia care and services for two residents, leading to unmanaged aggressive behaviors and expressions of wanting to die. The care plans lacked specific interventions, and staff were not adequately informed or trained to manage the residents' conditions effectively, placing them at risk for abuse and decreased quality of life.
The facility failed to notify the physician of abnormal blood sugars and did not monitor blood pressure before administering medication for a resident. Another resident received blood pressure medication and insulin despite physician orders to hold them if certain parameters were not met. These actions placed the residents at risk for adverse medication effects.
A resident with Alzheimer's received Seroquel without appropriate indication or documented physician rationale, including unsuccessful attempts for nonpharmacological symptom management. The facility's policy required addressing all potential causes of behavioral symptoms before considering antipsychotic medications, but this was not followed, placing the resident at risk for adverse side effects.
A resident with multiple health conditions received midodrine and metoprolol outside of physician-ordered blood pressure parameters multiple times over three months. Staff lacked understanding and proper communication regarding medication orders, and the facility failed to perform competency checks despite re-education efforts.
Failure to Prevent Facility-Acquired Pressure Injuries
Penalty
Summary
The facility failed to initiate effective interventions to prevent the development of facility-acquired pressure injuries for a resident who was admitted with multiple existing wounds and was dependent on staff for activities of daily living. The resident had diagnoses including metabolic encephalopathy, anemia, a right femur fracture, pneumonia, and nicotine dependency. Admission assessments documented intact cognition, wheelchair use for mobility, substantial assistance needed for transfers and other ADLs, a Braden score of 16 indicating mild risk, a pressure-reducing mattress that was later changed to a low air loss mattress, a wheelchair cushion, and a plan for staff to assist with turning, repositioning, and weight shifting while in the chair. The resident’s records showed existing pressure-related wounds on admission, including a stage 3 coccyx wound and an unstageable right heel wound, but the facility later identified new facility-acquired pressure injuries on the left middle toe and left lateral foot. Wound assessments documented the left middle toe wound as unstageable with hard necrotic tissue and the left lateral foot wound as a deep tissue pressure injury. The record also showed only two weekly skin observations during the six weeks after admission, and one weekly skin observation lacked laterality and further wound description. A physician ordered treatment for the left lateral foot wound on 01/12/26 and later ordered treatment for the left middle toe wound on 01/28/26. During observation, the resident was found lying in bed while a nurse cleansed and dressed the left middle toe and left lateral foot wounds. The toe had a black area, swelling, redness, and a small amount of serous drainage, and the resident complained of discomfort during the dressing change. Administrative nursing staff verified that the resident developed the left middle toe and left lateral foot pressure injuries approximately four weeks after admission, that the resident had been assessed as at risk for pressure injury development, and that he lacked pressure-relieving boots on admission. The facility’s pressure injury prevention policy stated that evidence-based interventions should be implemented for residents at risk or with pressure injuries, including preventive devices such as heel flotation devices, cushions, and mattresses, and that interventions should be documented in the care plan and communicated to staff.
Failure to Inform Residents of Ombudsman and State Agency Contact Information
Penalty
Summary
The facility failed to inform residents of the posting of the Ombudsman and State Agency contact numbers. The facility had a census of 70 residents, and the sample included 18 residents. Surveyors observed on 01/27/26 that the State Agency and Ombudsman information posters were located in the front portion of the building lobby/hallway area, but the resident council minute review from 01/2025 through 01/2026 did not include information about the Ombudsman and State Agency posting. On 01/28/26, the Resident Council President, Resident 12, stated the council had not been informed of the Ombudsman and State Agency contact information. On 01/29/26, Activity Staff Z stated that information regarding the Ombudsman and State Agency reporting had been shared during resident council meetings, but it had not been recorded in the resident council meeting minutes. Administrative Staff A stated the information should be reviewed with the council at least annually. The facility's undated policy stated that required Ombudsman and state agency notices shall be prominently posted in locations readily accessible and visible to residents, resident representatives, and the public, and that posting shall be reviewed at least annually and whenever there is a change in contact information or regulatory requirements.
Resident Council Not Informed of Survey Results Location
Penalty
Summary
The facility failed to inform the resident council of the location of the state inspection report. The State Agency inspection book was observed in the front lobby, but review of resident council minutes from 01/2025 through 01/2026 showed no information about where the state inspection results could be found. The Resident Council President, R12, stated the council had not been informed of the location of the state inspection results. Activity Staff Z reported that information about the Ombudsman and State Agency reporting was shared during resident council meetings, but it was not documented in the meeting minutes. Administrative Staff A stated the information should be reviewed with the council at least annually. The facility’s Resident Rights policy stated residents are to be informed orally and in writing of their rights, including the right to examine the results of the most recent survey and any plan of correction in effect.
Facility Assessment Not Available for Survey Review
Penalty
Summary
The facility failed to conduct a thorough facility-wide assessment to determine what resources were necessary to care for residents competently during day-to-day operations, including nights and weekends, and during emergencies. The facility had a census of 70 residents. On 01/28/26 at 09:00 AM, Administrative Staff A reported looking for the assessment but had not located it when the facility assessment was requested a second time. On 01/29/26 at 10:00 AM, Administrative Staff A reported that she could not locate the facility assessment, which she had completed and provided for the survey process on 01/27/26, along with a Quality Assurance Assessment (QAA) committee to be reviewed on 02/18/26. The facility’s Facility Assessment policy, dated 04/01/25, stated that the facility conducts and documents a facility-wide assessment to determine what resources are necessary to care for its residents competently during day-to-day operations and emergencies, and that the assessment is reviewed and updated as necessary and at least annually or whenever substantial changes occur.
Medication Storage and Temperature Monitoring Deficiencies
Penalty
Summary
The facility failed to label an open Lantus insulin pen with an open date in the 400 hall nurse medication cart. During observation, the pen for Resident 58 was found open without a date, and an LPN verified that the pen was open and stated staff should date a Lantus pen when they open it. An Administrative Nurse later stated that insulin pens should be dated when opened. The facility’s Medication Storage Policy stated that medications on the premises would be stored according to the manufacturer’s recommendations. The facility also failed to consistently record refrigerator temperatures in the south medication room and failed to keep an emergency treatment cart locked. During tour, the medication refrigerator temperature log showed only part of the month posted and temperatures recorded on only several days, while an LPN reported the refrigerator was to be checked each night by night shift nurses. A treatment cart in the middle hall was found unlocked and contained Naloxone HCL Nasal Spray with an expiration date of 06/2025, along with Liquid Skin and Derma Clenz labeled to keep out of reach of children. An Administrative Staff member verified the expired naloxone label and the storage instructions, stated the cart should be locked, and locked it at that time. An Administrative Nurse later verified that medication room refrigerators should be checked and recorded daily and that the treatment cart should be locked when not in use.
Incomplete Hair Restraints During Food Preparation
Penalty
Summary
The facility failed to prepare and serve food in a sanitary manner when dietary staff did not complete required hair coverage while working in the kitchen. On 01/27/26 at 08:00 AM, dietary staff were observed preparing and serving breakfast, and Dietary Staff (DS) CC had a beard and mustache but did not wear a beard or facial cover while preparing drinks for residents. On 01/28/26 at 11:00 AM, DS DD was observed with a beard and mustache, wearing a beard cover but not covering his mustache, while washing dishes and preparing salads for lunch. Later that day at 11:40 AM, DS EE walked through the dining room door into the back of the kitchen, grabbed a hair net, and then walked through the kitchen where staff were preparing the lunch meal before rolling her mid-length hair into a low bun and putting it in the hair net. At 11:45 AM, DS BB stated DS EE walked through the kitchen before wearing a hair net and confirmed staff were to wear hairnets while in the kitchen, and also verified DS CC lacked a beard and mustache cover and should have thorough hair coverage including mustaches with a beard/facial cover.
QAA Program Failed to Identify Multiple Facility-Wide Deficiencies
Penalty
Summary
The facility’s QAA program failed to identify multiple issues of concern affecting residents across the building, including failures related to resident rights, resident council communication, medication security, transfer notifications, care planning, bathing preferences, treatment documentation, pressure ulcer prevention, smoking assessment, infection control, dietary sanitation, facility assessment, and vaccination tracking. The report states that the facility had a census of 70 residents and that the sample included 18 residents, with findings showing the QAA program did not provide good faith efforts to identify these issues for 33 residents residing in the facility. Specific findings included failure to document review of resident rights with the resident council and failure to inform the council where the survey results book, ombudsman contact information, and state agency contact information were kept. The facility also failed to prevent misappropriation and diversion of liquid morphine, failed to provide bed hold notifications and ombudsman notifications for residents transferred to the hospital, failed to update care plans for a resident with a leg injury and another resident with a smoking section, failed to consistently provide bathing as preferred, failed to provide treatment when a resident’s blood sugar was in the 30s, failed to document a resident’s condition before ER/hospital transfer, failed to document care for a resident who later required 17 sutures to the leg, and failed to provide interventions for pressure ulcers and a smoking assessment. Additional findings included unsecured and improperly labeled medications and supplies, inconsistent refrigerator temperature documentation, dietary staff not using proper hair and beard coverings, failure to establish a facility assessment, multiple system failures, inadequate EBP and legionella-related infection control practices, and failure to determine which residents were eligible for Prevnar 20 vaccination.
Infection Control and Water Management Failures
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program in several areas. Administrative staff verified the facility did not have a system to check for standing water in unoccupied rooms or to mitigate potential Legionella growth, and staff stated they were not aware of any routine water management checks. The facility’s Water Management Plan policy required a water management team, risk identification, control measures, control limits, and ongoing monitoring through TELS tasks, but those checks were not in place. The facility also failed to follow infection control procedures during resident care. On one occasion, a nurse cleaned an open abdominal wound on a resident with a G-tube and discarded gloves in the resident’s room. On another occasion, the same nurse administered medications through the resident’s G-tube and again discarded gloves in the room. For another resident with an indwelling catheter and oxygen, two CNAs assisted with repositioning and catheter drainage while wearing gloves but no gowns or other PPE, and they discarded gloves in the room. A nurse also provided wound care to a resident with an open abdominal wound and a G-tube while wearing gloves only. The facility further failed to follow enhanced barrier precautions for residents with indwelling catheters and wounds. One resident with a lower leg wound and indwelling catheter had no EBP signage in the room, and staff reported gowns were not worn for catheter care. Another resident with an indwelling catheter and a history of UTI also had no EBP signage or gowns available in or outside the room, and staff reported they did not wear gowns during catheter care. A third resident with an indwelling catheter likewise had no EBP signage, and staff reported no gown use during catheter care. In addition, a nurse exited a resident’s room carrying a glucometer machine with a bloody strip and walked down the hallway before discarding it in a sharps container on the nurse’s cart; the nurse later acknowledged he should have brought the cart to the room. Administrative staff stated the bloody strip should have been discarded in a sharps container in the resident’s room.
Failure to Document PCV20 Vaccine Offerings and Declinations
Penalty
Summary
Develop and implement policies and procedures for flu and pneumonia vaccinations was cited after record review and interviews showed the facility failed to offer, obtain an informed declination for, or document a physician contraindication for the pneumococcal PCV20 vaccine in accordance with current CDC guidance. The facility had a census of 70 residents, and the sample included 18 residents, with five residents reviewed for immunizations: R16, R31, R43, R55, and R56. Review of the clinical records for these residents showed no evidence that the facility or the resident representative received or signed consent to receive the pneumococcal PCV20 vaccine, or an informed declination for the vaccine. Each of the five residents had been admitted to the facility on [DATE], and each record lacked evidence that the resident had been offered or received a pneumococcal PCV20 vaccine since admission. During interview on 01/28/26 at 11:00 AM, Administrative Nurse E stated residents were offered pneumonia vaccines on admission and as indicated, and that the resident or representative would sign a consent or declination. Administrative Nurse E also verified that every resident in the building had not been reviewed to determine eligibility for the PCV20 vaccine and that the facility did not have a definitive system in place to determine who was eligible or whether eligible residents had been offered or declined the vaccination.
Failure to Provide Bed Hold Notices and Ombudsman Discharge Notifications
Penalty
Summary
The facility failed to provide written bed hold information to residents when they were transferred to the hospital and failed to notify the State Long Term Care Ombudsman of facility-initiated discharges. The report identified two residents, R20 and R2, whose records lacked evidence that the required bed hold notice was given to the resident or the resident’s representative at the time of transfer, and whose discharge notifications were not included in the Ombudsman reporting process. R20’s record showed multiple hospital transfers related to changes in condition, including episodes of fever, vomiting, low oxygen saturation, altered mental status, shortness of breath, weakness, confusion, and possible sepsis. R20 had diagnoses including DM, neuromuscular dysfunction of the bladder, dementia, schizophrenia, UTI, hydronephrosis, and a urogenital implant. The progress notes for the transfers lacked documentation of a discharge assessment and did not mention bed hold information being provided to R20 or the representative. On review of the Ombudsman monthly notification list, R20 was not included in the discharge notifications, and Social Service staff reported the discharge list from the computerized system did not include R20’s discharges and therefore was not sent to the Ombudsman. R2’s record showed a transfer to the emergency room after retching with black/brown emesis and a later return to the facility. R2 had diagnoses including dementia, CKD stage 3, dysphagia, and COPD. The clinical record lacked a bed hold policy signature and lacked documentation that staff notified the LTCO of the discharge to the hospital. Administrative staff verified the facility could not provide written evidence of the bed hold notice for R2 and stated the nurse who discharges the resident should have the resident or family sign the bed hold policy. Social Service staff also verified that R2 was not included in the monthly discharge report sent to the LTCO office.
Failure to Complete and Update Care Plans for Wound Prevention and Smoking Safety
Penalty
Summary
The facility failed to develop a complete care plan within 7 days of the comprehensive assessment and failed to have the care plan prepared, reviewed, and revised by an interdisciplinary team for at least two residents. For one resident with multiple diagnoses including adult failure to thrive, CHF, spinal stenosis, severe protein-calorie malnutrition, lymphedema, muscle weakness, unsteadiness on feet, and Parkinson's disease, the quarterly MDS documented significant assistance needs with mobility, transfers, dressing, and walking, along with skin tears and wound-related interventions. The care plan addressed impaired skin integrity and ADL deficits, but it did not include interventions to prevent further injury to the lower extremities after a laceration occurred during a transfer involving the bedframe. The resident's record showed a left calf wound requiring sutures and ongoing wound care orders. Progress notes documented assessment of the wound and dressing changes, but earlier notes did not identify the cause or incident related to the wound. The resident later stated that the injury occurred when a CNA was assisting him to bed and his leg hit something on the bed frame. Administrative staff later verified that the care plan lacked interventions to prevent further injury, and the facility's policy required a comprehensive care plan to include measurable objectives, timeframes, and services identified in the assessment and to be reviewed and revised by the IDT after each comprehensive and quarterly MDS. For another resident with diagnoses including metabolic encephalopathy, anemia, fracture right femur, pneumonia, and nicotine dependency, the admission MDS documented intact cognition, dependence with ADLs, wheelchair use, and supervision needs, while the CAA documented substantial assistance needs and non-ambulatory status. The resident's care plan addressed transfers and wheelchair use, but there was no smoking care plan even though encounter notes documented that the resident smoked half a pack of cigarettes a day. The smoking safety assessment stated the resident did not currently smoke or use electronic smoking devices, and administrative staff later acknowledged that the smoking assessment should have documented that the resident smoked and should have addressed whether he could smoke safely or what assistance was required.
Failure to Provide Required Bathing Assistance
Penalty
Summary
The facility failed to provide necessary bathing assistance for two residents who required staff help with activities of daily living. One resident had diagnoses of vascular dementia and sequelae of cerebral infarction, a BIMS score of 8 indicating moderately impaired cognition, and required substantial to maximal staff assistance with showering. The resident’s care plan directed staff to provide a sponge bath when a full bath or shower could not be tolerated, but the skin monitoring CNA shower review sheets showed no bath in November 2025, refusals on two dates in December 2025, and three baths in January 2026. The clinical record did not specify the resident’s scheduled bathing dates. An Administrative Nurse stated that refusals should be documented on the skin monitoring sheet, that bathing should be documented when provided, and that if a resident had not received a bath after two days of the scheduled bathing day, the nurse should be notified; she also stated staff should offer alternate bathing methods such as bed baths and bathing wipes. A second resident had diagnoses including DM, neuromuscular dysfunction of the bladder, dementia, schizophrenia, UTI, hydronephrosis, and an indwelling catheter, with moderately impaired cognition and dependence on staff for toileting, bathing, and lower-body dressing. The resident’s CAA documented total assistance was needed for toileting and bathing, and the care plan directed extensive assistance with bathing and to reassure the resident, leave, and return in five to ten minutes if resistant with ADLs. Review of bathing task and shower/skin monitoring sheets from 10/31/25 through 01/28/26 showed the resident received 8 showers out of 23 opportunities, including only two showers in November 2025 and December 2025 and four in January 2026. On observation, the resident’s hair was not combed and facial hair had several days’ growth. The facility’s Resident Showers Policy stated residents would be assisted with bathing to maintain proper hygiene, stimulate circulation, and help prevent skin issues, and that showers would be provided per request or facility schedule protocols and based upon safety.
Failure to Treat Hypoglycemia and Document Hospital Transfers
Penalty
Summary
The facility failed to provide care and treatment in accordance with professional standards of practice when staff did not provide treatment for Resident 6’s low blood sugar before transfer to the hospital. Resident 6 had Type 2 diabetes mellitus, moderate cognitive impairment, and a care plan directing staff to monitor for signs and symptoms of hypoglycemia. The record showed no documentation that glucagon was administered on 10/28/25 at the time of the incident, and the clinical record lacked a progress note describing the event. The EMT report documented that the EMT found Resident 6 lying in bed, responsive only to pain and not verbally responsive, with a blood glucose of 31. Facility staff were described as frantically fanning the resident and demanding glucagon, and staff reported they had given glucose gel but could not state the dose. Staff also reported they did not know when the resident last ate or whether insulin had been given with a meal. The EMT attempted IV access, then administered glucagon, after which the resident’s blood glucose increased to 45. The facility also failed to maintain documentation related to Resident 3’s transfer to the hospital. Resident 3 had multiple diagnoses including Parkinson’s disease, spinal stenosis, muscle weakness, unsteadiness on feet, and severe protein-calorie malnutrition, and required substantial to maximal assistance with transfers and mobility. The record lacked a nursing assessment of Resident 3’s condition before being sent to the hospital for evaluation after a left lower leg laceration. The progress notes before 11/14/25 did not describe the wound cause or the incident related to the wound. Resident 3 later stated that the injury occurred when a CNA was assisting him to bed and his leg hit the bed frame, resulting in a five-inch laceration that required 17 stitches. The facility further failed to document Resident 20’s transfer to the hospital. Resident 20 had diagnoses including diabetes mellitus, dementia, schizophrenia, neuromuscular dysfunction of the bladder, UTI, and hydronephrosis. The last progress note before the hospital transfer documented increased penile pain, an intact area, and that the catheter secure was missing because the resident often removed it. The catheter secure was placed and the resident was educated, but the progress notes lacked a discharge assessment and lacked a nursing assessment of the resident’s condition before being sent to the hospital for evaluation. The record later documented that Resident 20 returned to the facility on a stretcher with two attendants and was to receive an antibiotic through a peripheral line.
Failure to Investigate Unwitnessed Fall and Inaccurate Smoking Assessment
Penalty
Summary
The facility failed to fully investigate a resident’s unwitnessed fall and failed to identify causative factors or document related interventions to prevent further falls. The resident had Parkinson’s disease, hypoxia, hypertension, muscle weakness, and severe cognitive impairment with a BIMS score of 00. The care plan identified the resident as a high fall risk with poor safety awareness, wandering behaviors, and dependence on staff for transfers and mobility, with directions for staff to keep the call light within reach, keep the bed low, lock wheelchair brakes, and use shoes or nonskid socks. After a CNA changed the resident’s brief and left the resident in bed, the resident got out of bed, which was not typical for the resident, and fell in the room. The nurse documented that the resident appeared to hit her head on the roommate’s wheelchair and had a laceration to the left-center forehead with bleeding. Staff transferred the resident to bed, obtained vital signs, cleansed and dressed the wound, notified the physician, and sent the resident to the hospital because the resident was on Lovenox. The resident returned with three sutures to a 2 cm left forehead laceration and a small hematoma; the CT scan of the head, brain, and spine was within normal limits. The resident’s EMR contained no investigative notes showing that the facility determined the root cause of the fall or identified interventions to prevent recurrence, and the facility could not provide additional investigation information when asked. An administrative nurse confirmed the medical record documented the fall with forehead laceration and verified the facility did not investigate the incident. The facility’s policy required reporting and investigation of allegations of abuse, neglect, mistreatment, and injuries of unknown source, including obtaining statements and documenting actions taken in the medical record.
Failure to Account for Controlled Medications
Penalty
Summary
The facility failed to establish and implement a system to accurately reconcile the disposition of controlled medications and failed to account for all controlled substances. During observation of a controlled substance reconciliation, one bottle of morphine 20 mg/ml concentrate was found unaccounted for, and the missing medication was identified as belonging to Resident 16. Review of the pharmacy spreadsheet showed the morphine was listed with a prescription number, medication name, and date of delivery, but the bottle itself could not be accounted for. Staff interviews showed that nurses were counting narcotics at the end of shifts and comparing them with the controlled drug administration record, with discrepancies to be reported to the DON or ADON if the count remained off. An administrative nurse stated that staffing coordinators had been responsible for monitoring narcotics but no longer worked at the facility, and that night shift managers were also responsible for monitoring them. The administrative nurse verified that the facility did not currently have a system for monitoring narcotics and identifying potential diversion. The facility’s medication administration policy stated that narcotics were to be signed out in the narcotics log and documented in the electronic medical record when given, and that staff were not to share or borrow medications from other residents.
Failure to Ensure Resident-Centered and Safe Transfer/Discharge
Penalty
Summary
The facility failed to ensure that the transfer or discharge process met the resident's needs and preferences, and did not adequately prepare the resident for a safe transfer or discharge. The report identifies that the necessary steps to assess and address the resident's individual requirements and preferences during the transfer or discharge process were not completed, resulting in a deficiency related to resident-centered care and safe transition planning.
Missing Recapitulation of Stay in Discharge Documentation
Penalty
Summary
The facility failed to document a recapitulation of stay for three residents who were discharged from the facility. The facility’s discharge summary policy defined a recapitulation of stay as a concise summary of the resident’s stay and course of treatment in the facility, and directed that the discharge summary include diagnoses, course of illness or treatment, and pertinent labs, radiology, and consultation results. For one resident, the record showed diagnoses of major depressive disorder, repeated falls, and generalized anxiety disorder, with intact cognition on MDS assessments. The resident had discharge planning in progress, participated in social services meetings about returning to the community, and ultimately discharged to a motel in another town after self-discharge. The EMR contained social services notes, nursing notes, and discharge instructions, but lacked documentation of a discharge summary that included a recapitulation of stay. For a second resident, the record showed diagnoses of sepsis, generalized muscle weakness, and unsteadiness on feet, with intact cognition and a goal to discharge to the community. The EMR included discharge instructions and a discharge summary note stating the resident discharged home with home health and received medication review and education, but neither document included a recapitulation of stay. For a third resident, the record showed diagnoses of major depressive disorder, generalized muscle weakness, history of falling, and contusion of the right hip, with moderate cognitive impairment and no active discharge planning at admission. The resident later planned discharge to housing in another town with home health in place, but the discharge instructions were incomplete and the EMR lacked a discharge summary with a recapitulation of stay.
Failure to Assist Residents with Activities of Daily Living
Penalty
Summary
A deficiency was identified when care and assistance were not provided to perform activities of daily living (ADLs) for residents who were unable to do so themselves. The report notes that residents requiring help with ADLs did not receive the necessary support from facility staff, resulting in unmet care needs for those individuals. No additional details about the specific residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Implement Water Management Program and Inadequate Catheter Care
Penalty
Summary
The facility failed to implement a water management program to prevent Legionella disease, as required by the Centers for Medicare and Medicaid Services (CMS). Maintenance and administrative staff were unaware of the requirement, and the facility had no current program in place. This failure placed residents at risk of contracting Legionella pneumonia, particularly those over the age of 50 or with weakened immune systems, chronic lung disease, or heavy tobacco use. Additionally, the facility did not ensure adequate infection control practices related to catheter care. Observations revealed that staff did not use privacy bags for urinary catheter drainage bags, allowing urine to be visible from the hall. Staff also placed measuring containers on bare floors, did not disinfect catheter ports, and failed to change gloves or wash hands between handling different types of catheters. These practices were observed with multiple residents, including one who had recently completed antibiotic treatment for a urinary tract infection. Interviews with various staff members confirmed that the observed practices were not in line with the facility's policies. Staff acknowledged that catheter bags should not be placed on the floor, should be kept in privacy bags, and that proper hand hygiene and disinfection protocols should be followed. The facility's policies directed staff to maintain a clean technique, keep catheter tubing and drainage bags off the floor, and prevent contact of the drainage spigot with nonsterile containers. The failure to adhere to these policies placed residents at increased risk for infection.
Failure to Provide Required In-Service Education for Nursing Staff
Penalty
Summary
The facility failed to provide the required 12 hours of in-service education for Certified Medication Aides (CMAs) and Certified Nursing Assistants (CNAs). Specifically, CMAs R, RR, and SS, as well as CNA P, lacked documentation of the required training. This deficiency was identified through a review of the facility's annual in-service documentation and was confirmed by Administrative Nurse D, who has been serving as the Director of Nursing since November 2023. Administrative Nurse D acknowledged the absence of evidence showing that the sampled CNA staff had completed the required 12 hours of in-service education. The facility's Competency of Nursing Staff policy mandates that all nursing staff meet specific competency requirements as defined by state law, including annual and facility-specific competencies. Despite this policy, the facility did not ensure that the required in-service education was provided. This failure placed residents at risk of receiving impaired care, as the staff may not have been adequately trained to meet the residents' needs as identified through assessments and care plans.
Failure to Ensure Safe Environment and Prevent Accidents
Penalty
Summary
The facility failed to ensure an environment free from preventable accident hazards for a resident who burned his fingers while smoking. The resident, who had intact cognition and several medical conditions including neuromuscular dysfunction of the bladder, diabetes mellitus, and pneumonia, was not properly assessed for smoking safety upon admission. Despite a care plan that required supervision and the use of a cigarette holder and smoking apron, the resident burned his fingers twice due to a lack of feeling in his fingers. The facility did not conduct a timely smoking safety assessment or implement preventive actions to prevent future burns, placing the resident at risk for injuries and pain related to burns. Another resident with bilateral above-the-knee amputations, diabetes mellitus, dementia, and anxiety was also not properly assessed for smoking safety. The resident's last smoking safety assessment was conducted over two years ago, and the facility failed to re-evaluate the resident's ability to smoke safely on a quarterly basis as required by their policy. This oversight placed the resident at risk for preventable accidents and related injuries. Additionally, the facility failed to investigate and implement interventions to prevent falls and injuries for two other residents. One resident with congestive heart failure, diabetes mellitus, osteoporosis, dementia, and anxiety experienced multiple skin tears, but the facility did not investigate the incidents or develop preventive measures. Another resident with dementia, diabetes mellitus, and hypertension had a history of falls but lacked care-planned interventions to prevent further falls. The facility did not complete a fall investigation for one of the resident's falls and failed to implement resident-centered interventions to prevent falls, placing the resident at risk for further injuries.
Consultant Pharmacist Fails to Identify and Report Medication Errors
Penalty
Summary
The Consultant Pharmacist (CP) failed to identify and report medications administered outside of physician-ordered parameters for several residents, placing them at risk for adverse side effects and unnecessary medications. For Resident 15, the CP did not report that midodrine was administered 29 times when the resident's blood pressure was above the ordered parameters. Despite the pharmacist's recommendation to obtain hold parameters for another medication, there was no mention of the errors related to midodrine administration. This oversight was confirmed by the administrative nurse and a certified medication aide who admitted to not understanding the symbols indicating when to hold the medication. For Resident 31, the CP did not identify that staff failed to obtain blood pressure readings before administering lisinopril, a medication for hypertension, 78 times. The administrative nurse verified this oversight and expressed confusion as to why the pharmacist had not identified the issue. The facility's policy required the CP to perform a thorough medication regimen review to prevent and resolve medication-related problems, but this was not adhered to in this case. Resident 6 also experienced similar issues, with blood pressure medications and insulin being administered multiple times when the physician's orders indicated they should be held. The CP's monthly reviews did not note these discrepancies, and the administrative nurse confirmed the oversight. Additionally, Resident 4 was given Seroquel for an inappropriate indication (Alzheimer's), and the CP failed to recommend an appropriate indication for its continued use. The administrative nurse verified that the pharmacist had sent monthly reviews but did not address the inappropriate use of Seroquel.
Failure to Properly Label and Discard Insulin
Penalty
Summary
The facility failed to properly label and manage insulin medications for three residents, leading to potential risks for ineffective medication administration. Specifically, the insulin flex pens for two residents were not dated when opened, and an outdated insulin vial for another resident was not discarded. These observations were made during a survey of the facility's medication carts, where it was found that the Humalog flex pens for two residents lacked both an open date and a discard date. Additionally, a Lantus vial for another resident had an open date that indicated it should have been discarded but was still present in the medication cart. Administrative Nurse D confirmed that the facility's protocol requires nurses to date insulin when opened and discard it when outdated. The facility's Insulin Administration policy also mandates that the expiration date be recorded on the vial when opened. The failure to adhere to these protocols was verified by the administrative nurse, who acknowledged that the night nurse should check for expired medications and that every nurse administering medications should ensure they are not outdated. This lapse in protocol placed the residents at risk for receiving ineffective medications.
Failure to Investigate Injuries of Unknown Origin
Penalty
Summary
The facility failed to ensure staff identified injuries of unknown origin as potential allegations of abuse and report them to the administrator for investigation. This deficiency was observed in the case of a resident with severe cognitive impairment and multiple medical conditions, including congestive heart failure, diabetes mellitus, osteoporosis, dementia, and anxiety. The resident, who was dependent on staff for most activities of daily living and used a wheelchair for mobility, sustained two skin tears on separate occasions. The first injury was a large skin tear on the right lower extremity, and the second was a skin tear on the right lateral calf. Despite these injuries, the facility's records lacked any investigative notes, and administrative staff were unaware of how the injuries occurred, indicating that no investigation was completed to determine the cause of the injuries. The facility's policy on Accident and Incidents-Investigating and Reporting required that all accidents or incidents involving residents be investigated and reported to the administrator. However, the facility staff failed to follow this policy, as evidenced by the lack of investigation into the resident's injuries. The administrative nurse confirmed that the facility did not investigate the incidents to determine their cause. This failure to identify and investigate injuries of unknown origin placed the resident at risk for unidentified and ongoing abuse and/or neglect.
Failure to Investigate Injuries of Unknown Origin
Penalty
Summary
The facility failed to investigate two injuries of unknown origin for a resident, which could have ruled out possible abuse or neglect. The resident had a history of congestive heart failure, diabetes mellitus, osteoporosis, dementia, and anxiety, and was dependent on staff for most activities of daily living. The resident's medical records documented a large skin tear on the right lower extremity on one occasion and a skin tear on the right lateral calf on another occasion. Despite these injuries, the facility did not conduct any investigation to determine the cause of the injuries, as confirmed by the administrative nurse. The facility's policy required that all accidents or incidents involving residents be investigated and reported to the administrator, with specific data included in the report. However, the facility did not follow this policy for the resident's injuries. The lack of investigation placed the resident at risk for unidentified and ongoing abuse or neglect. The facility's failure to investigate these injuries was a clear violation of their own policies and procedures, as well as a failure to ensure the safety and well-being of the resident.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for three residents, leading to impaired care due to uncommunicated care needs. Resident 31, diagnosed with dementia, diabetes mellitus, and hypertension, had a care plan that lacked interventions for managing diabetes and preventing falls. Despite multiple falls and blood sugar levels outside the ordered parameters, the care plan did not provide adequate direction to staff, and the physician was not notified of abnormal blood sugar levels on numerous occasions. Observations revealed that Resident 31 was often left unattended, increasing the risk of falls and further injury. Resident 77, with diagnoses including vascular dementia, depressive disorder, and diabetes mellitus, exhibited behaviors such as refusing care, expressing a desire to die, and urinating on the floor. The care plan did not address these behaviors or provide interventions for managing the resident's mood and verbalizations of wanting to die. Despite multiple incidents of aggressive behavior and statements about self-harm, the facility did not follow up with psychiatric evaluations or implement consistent safety checks. Staff were aware of the resident's behaviors but did not take appropriate actions to address them in the care plan. Resident 29, admitted with neuromuscular dysfunction of the bladder, diabetes mellitus, and pneumonia, began smoking at the facility but did not have a comprehensive care plan for smoking safety. After burning his finger while smoking, the resident's care plan was updated to include supervision and the use of a cigarette holder and smoking apron. However, the facility failed to perform a smoking assessment when the resident started smoking and did not document the burn on the skin assessment. Staff did not reassess the resident's smoking practices after the incident, leading to continued risk of injury.
Failure to Review and Revise Care Plans for Pain Management and Skin Tear Prevention
Penalty
Summary
The facility failed to review and revise the care plan for a resident with chronic pain, leading to inadequate pain management. The resident, who had diagnoses including alcohol dependence, chronic pain in the right shoulder, and dorsalgia, reported constant severe pain that interfered with sleep and activities. Despite receiving scheduled and PRN pain medications, the care plan lacked non-medication pain relief measures. Observations and interviews revealed that the resident's pain was not adequately managed, and alternative pain relief interventions were not offered or documented by the staff. The facility's care planning policy was not followed, resulting in uncommunicated care needs and impaired care for the resident. Another resident with diagnoses including congestive heart failure, diabetes mellitus, osteoporosis, dementia, and anxiety experienced skin tears that were not adequately addressed in the care plan. The resident, who had severely impaired cognition and was dependent on staff for most activities of daily living, had a care plan that directed staff to use pressure-reducing measures and provide substantial assistance with transfers. However, after skin tears occurred, the care plan was not updated with new interventions to prevent further injuries. The facility also failed to investigate the incidents, leaving the causes of the skin tears unknown. Observations and interviews confirmed that the facility did not follow its care planning policy, resulting in uncommunicated care needs and increased risk of injuries for the resident. The facility's failure to review and revise care plans for pain management and skin tear prevention led to impaired care for the residents. The care plans did not include necessary interventions, and the facility did not investigate incidents or document alternative measures. This lack of communication and adherence to care planning policies placed the residents at risk for inadequate care and further injuries.
Failure to Provide Necessary Bathing Services
Penalty
Summary
The facility failed to provide necessary services to maintain good personal hygiene, including bathing, for three residents, placing them at risk for impaired health and decreased psychosocial well-being. Resident 4, diagnosed with Alzheimer's, major depressive disorder, congestive heart failure, and atrial fibrillation, required substantial assistance for most activities of daily living, including bathing. Despite being scheduled for showers twice a week, documentation revealed multiple instances where the resident refused showers without any follow-up or reapproach by staff, resulting in the resident not receiving a shower for extended periods. Resident 41, with diagnoses including bilateral above-the-knee amputations, diabetes mellitus, dementia, and anxiety, also required extensive assistance for bathing. The resident's records showed numerous refusals of showers without follow-up or reapproach, leading to significant gaps between showers. Observations confirmed the resident's unkempt appearance, and staff verified the lack of documentation and follow-up for missed showers. Resident 30, who had chronic pain and dorsalgia, required partial moderate assistance for bathing. Despite having intact cognition and no rejection of care behavior, the resident's records indicated consistent refusals of showers without evidence of reapproach or alternative hygiene options being offered. Staff interviews revealed a lack of coordination and follow-up for missed showers, and observations confirmed the resident's unclean state. The facility's policy required documentation of refusals and follow-up actions, which were not adhered to, resulting in the failure to provide necessary care and bathing services for these residents.
Deficient Catheter Care and Infection Control Practices
Penalty
Summary
The facility failed to provide appropriate care and services to prevent potential infection of the urinary system for two residents, R29 and R17, during care for their urinary catheters. For R29, the facility did not maintain proper infection control practices. Observations revealed that the urinary catheter bag was frequently placed on the floor without a privacy cover. Additionally, staff did not use disinfectant wipes on the catheter port and placed a measuring canister on a visibly soiled floor. These actions were contrary to the facility's policy, which required maintaining a clean technique and ensuring the catheter tubing and drainage bag were kept off the floor. R29 had a history of neuromuscular dysfunction of the bladder, diabetes mellitus, and recurrent urinary tract infections, which placed him at higher risk for complications. Despite these conditions, the facility's staff failed to adhere to proper catheter care protocols, leading to an increased risk of infection and other catheter-related complications for R29. Similarly, R17's care was compromised due to improper handling of the urinary catheter and nephrostomy bags. Observations showed that the urinary catheter drainage bag was hung on the side of the bed without a privacy bag, making the urine visible from the hall. Staff placed a measuring container on the bare floor and did not disinfect the catheter port before and after emptying the urine. Additionally, staff did not change gloves or wash hands between handling the Foley and nephrostomy bags. These actions were inconsistent with the facility's policy, which required maintaining a clean technique, using alcohol wipes on the port, and changing gloves between tasks. R17 had a history of diabetes mellitus, obstructive and reflux uropathy, paraplegia, and recurrent urinary tract infections, making her particularly vulnerable to infections. The facility's failure to follow proper catheter care protocols placed R17 at increased risk for infection and other catheter-related complications. The facility's policies on catheter care, dated 2014, directed staff to maintain an accurate record of daily output, keep the tubing free of kinks, and always position the drainage bag lower than the bladder. Staff were also required to maintain a clean technique when handling or manipulating the catheter, tubing, or drainage bag, and to ensure the catheter tubing and drainage bag were kept off the floor. Despite these clear guidelines, the facility failed to ensure appropriate catheter care and services for both R29 and R17, leading to deficiencies in infection control practices and placing the residents at risk for catheter-related complications.
Failure to Provide Non-Medicinal Pain Relief Measures
Penalty
Summary
The facility failed to provide non-medicinal pain relief measures and promote effective pain management for a resident (R30) who experienced almost constant severe pain. R30 had diagnoses of alcohol dependence, chronic pain in the right shoulder, and dorsalgia. Despite receiving scheduled and PRN pain medications, including Tylenol and oxycodone, R30 reported that his pain control was inadequate. The care plan for R30 lacked direction for non-medication pain relief measures, and the EMR did not show evidence that staff consistently offered or attempted non-pharmacological interventions to treat pain. Observations and interviews revealed that R30 was not offered alternative pain interventions such as heat or cold therapy, aromatherapy, or music therapy, and staff primarily relied on medication to manage his pain. R30's care plan directed staff to administer analgesia per orders, evaluate the effectiveness of pain interventions, and notify the physician if interventions were unsuccessful. However, the care plan did not include specific non-medication pain relief measures. The facility's Pain-Clinical Protocol policy stated that staff should provide elements of a comforting environment and appropriate physical and complementary interventions, but this was not consistently implemented for R30. The resident's pain level remained high, and he frequently sought pain medication, indicating that the current pain management strategies were ineffective. Interviews with staff members, including a CNA and a licensed nurse, confirmed that non-medication pain relief interventions were not consistently offered to R30. The administrative nurse acknowledged that staff should have offered alternative pain relief measures and documented their attempts. The facility's failure to provide non-medicinal pain relief measures and promote effective pain management for R30 placed the resident at risk for ongoing severe pain and impaired quality of life.
Failure to Provide Adequate Dementia Care and Behavioral Health Services
Penalty
Summary
The facility failed to provide the necessary dementia care and services to attain or maintain the highest level of practicable physical, mental, and psychosocial well-being for two residents, R26 and R77. R26 had diagnoses of mild cognitive impairment, cognitive communication deficit, and cerebral infarction. Despite displaying aggressive behaviors such as hitting, biting, and attempting to pull her roommate out of bed, the facility did not investigate the incident to identify potential triggers or causative factors. Additionally, R26's care plan lacked specific interventions related to her cognitive impairment and behaviors, and staff were not adequately informed or trained to manage her behaviors effectively. R77 had diagnoses of vascular dementia, depressive disorder, cerebral infarction, hemiparesis/hemiplegia, epilepsy, and diabetes mellitus. Despite multiple instances of expressing a desire to die, refusing care, and displaying aggressive behaviors such as kicking and scratching staff, the facility did not provide adequate person-centered interventions. The care plan for R77 lacked direction regarding his mood and verbalizations of wanting to die. The facility also failed to follow up with a Geri-Psych hospital for placement and did not implement consistent safety checks or alternative interventions when R77 refused to see a therapist. The facility's Behavioral Health Services policy stated that residents would receive behavioral health services as needed to attain or maintain the highest practicable physical, mental, and psychosocial well-being. However, the facility did not adhere to this policy for both R26 and R77. The lack of person-centered interventions and failure to investigate and address the residents' behaviors placed them at risk for abuse and decreased quality of life.
Failure to Follow Physician Orders for Medication Administration
Penalty
Summary
The facility failed to notify the physician of blood sugars outside of ordered parameters for Resident 31 and did not monitor Resident 31's blood pressure before administering medication for high blood pressure. Resident 31 had diagnoses of dementia, diabetes mellitus, and hypertension. The care plan for Resident 31 lacked interventions or directions for monitoring side effects from medications related to diabetes and hypertension. The Treatment Administration Record (TAR) documented multiple instances where blood sugars were outside the ordered parameters, and the physician was not notified. Additionally, there was no documentation of blood pressure being checked before administering lisinopril for 78 administrations since the start of the medication. The facility also failed to hold blood pressure medication and insulin when the medication was out of the physician-ordered parameters for Resident 6. Resident 6 had diagnoses of hypertension and diabetes mellitus and was independent for most activities of daily living. The Medication Administration Record (MAR) documented several instances where blood pressure medications and insulin were administered despite the physician's orders to hold them if certain parameters were not met. Specifically, hydralazine, Cozaar, and metoprolol were administered multiple times when the systolic blood pressure was less than 110 mmHg, and Humalog insulin was administered when the finger stick blood sugar was less than 110 mg/dL. Observations and interviews with staff confirmed these deficiencies. Administrative Nurse D verified that the care plan for Resident 31's diabetes should have been completed and that blood sugars outside of the ordered parameters were not reported to the physician. Additionally, it was confirmed that staff had not obtained Resident 31's blood pressure before administering blood pressure medication. For Resident 6, it was verified that staff should have held the insulin and blood pressure medications as ordered when the parameters were not met. The facility's policies on administering medications and monitoring vital signs were not followed, placing the residents at risk for adverse medication effects.
Inappropriate Use of Antipsychotic Medication
Penalty
Summary
The facility failed to ensure an appropriate indication or a documented physician rationale for the continued use of antipsychotic medication for a resident diagnosed with Alzheimer's. The resident's electronic medical record lacked documentation of unsuccessful attempts for nonpharmacological symptom management and a risk versus benefits analysis for the continued use of Seroquel. The resident's care plan noted the use of antipsychotic medication and the need for monitoring side effects, but the physician's order did not provide a valid indication for the medication's use. Observations revealed that the resident received Seroquel despite spitting out other medications, and the administrative nurse confirmed the inappropriate indication for the antipsychotic medication. The facility's policy on antipsychotic medication use required that all potential causes of behavioral symptoms be identified and addressed before considering such medications. However, the facility did not adhere to this policy, as evidenced by the lack of documented rationale and nonpharmacological interventions for the resident. This failure placed the resident at risk for adverse medication side effects, as the facility did not ensure the antipsychotic medication was used appropriately and with proper documentation.
Failure to Prevent Significant Medication Errors
Penalty
Summary
The facility failed to prevent significant medication errors for a resident diagnosed with end-stage renal disease, hypertension, diabetes mellitus, hypotension, and heart failure. The resident's care plan required staff to administer medications as ordered and monitor for side effects. However, the resident's Medication Administration Records (MAR) for January, February, and March 2024 documented multiple instances where the resident received midodrine and metoprolol outside of the physician-ordered blood pressure parameters. Specifically, midodrine was administered 74 times when the resident's blood pressure was above the ordered parameters, and metoprolol was administered three times when the resident's blood pressure was below the ordered parameters. These errors were not consistently identified or corrected by the staff, despite education and recommendations from the pharmacist regarding the errors in February 2024. Interviews with staff revealed a lack of understanding and proper communication regarding the medication orders and blood pressure parameters. A Certified Medication Aide admitted to not understanding the symbols indicating when to hold the medication, and a Licensed Nurse stated that he did not always check the MAR for blood pressure readings before administering medication. The Administrative Nurse acknowledged that re-education had been provided but no competency checks were performed on the staff who made the errors. The facility's policy required immediate action in the event of significant medication errors, but this was not effectively implemented, placing the resident at risk for adverse medication reactions and physical decline.
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Illustrative
What surveyors actually found near you
We read the 428 citations issued within 25 miles in the last 12 months — including the 8 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Tonganoxie
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hillside Village Of De Soto Rehabilitation And Nur | 10.5 mi | ★★★★★ | 7 | 0 |
| Bonner Springs Nursing & Rehab Center | 11.1 mi | ★★★★★ | 0 | 0 |
| Medicalodges Eudora | 11.6 mi | ★★★★★ | 1 | 1 |
| Lawrence Memorial Hospital Snf | 12.4 mi | ★★★★★ | 0 | 0 |
| Lansing Care And Rehab | 14.3 mi | ★★★★★ | 22 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.