Average — CMS composite of the measures below.
The next survey window likely opens around September 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 Johnson County Care Center during CMS and state inspections, most recent first.
The facility failed to implement Enhanced Barrier Precautions (EBP) for multiple residents with chronic foot wounds, vascular leg wounds, and documented wound infections, despite having a written EBP policy and CDC guidance requiring gown and glove use during high-contact care such as wound care, hygiene, and dressing changes. Observations showed that the DON performed wound care using gloves and hand hygiene but without a gown, and there were no EBP signs or PPE supplies posted outside resident rooms. Additional residents with diabetic ulcers and chronic plantar wounds received daily wound treatments without EBP measures in place. Interviews with a CMT, an LPN, the DON, the Administrator, and the Infection Preventionist revealed that staff were not educated on EBP, gowns were rarely used for wound care, some nurses were reported to perform wound treatments without gloves, and key leaders were unaware of or had not implemented EBP in the facility.
The facility failed to provide proof of RN coverage for 8 consecutive hours a day on multiple dates across several PBJ quarters. PBJ data showed no RN coverage on the listed dates, and the facility could not produce documentation showing the required RN hours. The Administrator acknowledged the staffing shortfall and said the facility had been trying to hire RNs, while the DON stated he/she was not involved in staffing and was unaware of the prior noncompliance.
The facility failed to maintain a complete infection prevention and control program for Legionella and other water-borne pathogens, with missing CDC toolkit elements, risk assessment, water system documentation, testing protocols, and log records. An LPN did not perform proper hand hygiene during medication passes for three residents and during wound care for a resident with foot wounds and osteomyelitis, including after touching the floor and between dirty wound-care tasks. The facility also failed to complete and document employee TB testing according to policy and CDC guidance for multiple staff members.
Missing Acetaminophen Order Parameters: Three residents had Acetaminophen orders that did not include the required 3 g/24-hour limit from all sources. LPNs stated the limit should have been present on all such orders and that missing parameters should have been obtained from the physician. The DON said it was the expectation that nurses ensure the parameter was added and that he/she was ultimately responsible for ensuring all Acetaminophen orders included the limit.
Failure to ensure 10 NAs became CNAs within the required 4-month timeframe. Record review showed multiple NAs remained in NA status beyond 4 months after hire, and interviews confirmed some had only recently started CNA class despite months of employment. The Administrator acknowledged awareness of the 4-month limit and said some NAs stayed longer due to staffing shortages, while the DON said he/she was unaware of the issue and did not know the 4-month requirement.
A resident with chronic foot wounds, osteomyelitis, and poor circulation had inconsistent wound documentation, missing initial assessments, and gaps in weekly wound tracking. An LPN who lacked specialized wound training said weekly assessments had stopped, and during wound care the LPN treated a new open area with calcium alginate before obtaining a physician order. The DON confirmed the weekly assessments were not consistently completed and that staff were relying on TAR entries for skin they could see while the resident’s feet were usually bandaged.
Delayed fall investigations and outdated care plans after repeated resident falls. Two residents with significant fall risk factors, including dementia, Parkinsonism, hallucinations, poor balance, and poor safety awareness, had multiple unwitnessed falls with injury or bruising. Staff did not complete the fall investigations promptly, no RCA was completed for the falls, and the care plans were not updated to reflect the new falls or interventions. Interviews showed staff were unsure who was responsible for the investigations and care plan updates, and the DON stated oversight had not been maintained.
Improper Positioning During Tube Feeding: A resident with a G-tube, cerebral palsy, and severe cognitive impairment was observed multiple times with tube feeding running while the HOB was below the required angle, including sliding down in bed, slumping to the side, and lying flat. The care plan required continuous HOB elevation, and staff interviews confirmed the resident should not have been flat during tube feeding and needed frequent monitoring because of sliding in bed.
Medication error rate exceeded the 5% limit when an LPN crushed a resident’s Depakote delayed-release tablets during a med pass and mixed them into pudding. The resident had epilepsy, intractable epilepsy with status epilepticus, and generalized idiopathic epilepsy, and the facility’s own staff and Depakote product information stated the tablets should not be crushed.
The facility failed to maintain RN coverage for eight consecutive hours daily from July 2023 to March 2024, with the DON serving as charge nurse despite a census over 60 residents. The DON was the only RN, and the facility lacked a staffing policy document.
The facility failed to maintain a comprehensive infection prevention and control program, lacking a Legionella risk management plan, CDC toolkit, and proper infection tracking. The infection control book was incomplete, missing 12 months of data and details on infections. Additionally, two residents did not receive required TB assessments. The Maintenance Supervisor and DON were unaware of full program requirements.
The facility failed to implement an effective antibiotic stewardship program, as evidenced by incomplete infection tracking logs and missing documentation of lab results and symptoms for antibiotic use. The Director of Nursing, responsible for the program, could not locate necessary records, indicating non-compliance with the facility's policy.
The facility did not designate a qualified individual as the Infection Preventionist (IP) for its Infection Prevention Control Program. The DON was intended to take on the IP role but had not completed the necessary certification classes. The Administrator, who held an IP certificate, had a degree in Social Work, which is not an approved primary professional medical training. The facility also lacked a policy on the required training for the IP role.
A resident with an unstageable pressure ulcer did not receive appropriate care due to the facility's failure to have a policy or physician's order for a low air loss mattress, incorrect mattress settings, and incomplete wound assessments. The care plan was not updated to reflect the current stage of the ulcer, and documentation inconsistently identified the wound type and lacked detailed descriptions. Staff interviews revealed a lack of awareness and adherence to proper procedures.
A facility failed to follow professional standards for verifying gastrostomy tube placement, using outdated methods instead of measuring and documenting tube length. A resident with cerebral palsy, reliant on tube feeding, experienced inconsistencies in feeding infusion due to incorrect physician orders and lack of proper verification by staff. The DON and other staff were unaware of current standards, leading to deficiencies in care.
The facility failed to provide Trauma Informed Care (TIC) assessment and care planning for two residents diagnosed with PTSD. The care plans lacked interventions specific to TIC needs, such as identifying triggers and steps to mitigate them. Staff interviews revealed a lack of awareness and training regarding the residents' PTSD diagnoses and TIC principles. The facility's failure to incorporate TIC assessments and care planning resulted in a deficiency in providing trauma-informed and culturally competent care.
A facility failed to ensure timely physician response to a pharmacist's recommendation for gradual dose reduction (GDR) of psychotropic medications for a resident with severe cognitive impairment and multiple mental health diagnoses. The consultant pharmacist recommended GDRs for several medications, but there was no documented physician response, and a GDR had not been attempted or documented as clinically contraindicated. The DON, responsible for reviewing and implementing pharmacy recommendations, did not follow up with the physician to obtain a reason for not following the recommendation.
The facility did not post daily staffing information, including staff titles and hours worked, on the second and third floors, potentially affecting all residents. The MDS Coordinator noted the information was posted by the time clock on the first floor, not visible to upper floors. The DON stated the BOM was responsible for posting it visibly for all residents and visitors.
Failure to Implement Enhanced Barrier Precautions for Residents With Wounds
Penalty
Summary
The deficiency involves the facility’s failure to implement its own Enhanced Barrier Precautions (EBP) policy and CDC-recommended practices for residents with wounds and infection risks. The facility’s EBP policy required gown and glove use for residents with certain infections, wounds, and/or indwelling medical devices during high-contact resident care activities such as dressing, bathing, transferring, providing hygiene, changing linens and briefs, toileting assistance, device care, and wound care. CDC guidance similarly called for hand hygiene for everyone entering and leaving the room and gown and glove use for high-contact care activities for residents who meet EBP criteria. Surveyors found that EBP was not being used for any of the sampled residents with wounds, and staff and leadership reported they had not discussed or implemented EBP in the facility. One resident had diabetes, a skin infection, and a non-pressure chronic ulcer of the left foot, with a documented diabetic foot ulcer and wound infection. The care plan identified skin impairment related to diabetes and a chronic wound, and the treatment record showed ongoing wound care to the left great toe, including cleansing and application of Iodoflex and dressings. A wound care provider note documented a chronic left great toe wound, prior IV antibiotics for chronic osteomyelitis, and a long-standing diabetic ulcer with specific measurements and wound characteristics including serosanguineous exudate, slough, granulation tissue, and necrotic tissue. During observed wound care by the DON, there were no EBP signs or PPE outside the room, the DON wore gloves and performed hand hygiene but did not wear a gown, and the DON stated they had not talked about or used EBP at the facility. Another resident with diabetes had documented abrasions to both knees and a vascular wound to the left lower leg, with physician orders for daily cleansing and application of calcium alginate and foam dressings to the left lower extremity wound. Observation showed dressings on both shins and no EBP signage or PPE outside the room. The DON again stated that EBP had not been discussed or used. A third resident had an open wound on the left foot, osteomyelitis, and a chronic foot wound, with care plan entries for risk of infection and actual skin integrity impairment related to a chronic foot wound. Treatment orders included cleansing and dressing of plantar areas on both feet and application of calcium alginate to an open wound on the right foot, with skin observation documenting a callous on the left foot and a chronic wound on the right plantar surface. During observation, there were no EBP signs or PPE outside the room, the DON reported the resident had wounds on the bottom of both feet, and confirmed that EBP had not been discussed or used. Staff interviews further demonstrated the lack of implementation of EBP and incomplete use of PPE during wound care. A Certified Medication Technician reported hardly ever seeing nurses use gloves during wound treatments, seeing nurses perform wound treatments without gowns, and not knowing where gowns were located. The DON stated they had not talked about EBP and had not used EBP for any residents. The Administrator reported that EBP had not been done and did not believe the facility had an EBP policy, despite the written policy reviewed by surveyors. The Infection Preventionist stated they had never heard of EBP prior to the survey date. An LPN reported that administration had not instructed staff to use EBP, that they only wore gloves during wound treatments, and that they did not wear gowns when performing wound care. These observations and interviews show that the facility did not implement EBP for residents with wounds as required by its policy and CDC guidance.
Failure to Maintain Required RN Coverage
Penalty
Summary
The facility failed to provide proof of RN coverage for eight consecutive hours a day on multiple dates across FY Quarter Four 2024, FY Quarter One 2025, FY Quarter Two 2025, and FY Quarter Three 2025. The PBJ reports showed no RN coverage on the listed dates in each quarter, and when documentation was requested, the facility was unable to produce records showing RN coverage for eight hours per day. The facility census was 75 residents, and the undated staffing policy stated that the facility would use the services of an RN for at least eight hours a day, seven days a week. During interview, the Administrator stated that staffing was being overseen by management because the DON had only started about two months earlier, and acknowledged that the facility had not met the eight-hour RN requirement. The Administrator said the facility had been trying to hire RNs, had just hired a DON two months ago, and did not use agency staff by policy. The DON stated that he/she was not doing staffing at the time, knew the facility had just gotten fully staffed with RNs, and did not know the facility had not been meeting the RN requirement before being hired.
Infection Control Program, Hand Hygiene, and TB Testing Failures
Penalty
Summary
The facility failed to establish and maintain a comprehensive infection prevention and control program for Legionella and other water-borne pathogens. The Legionella program paperwork in the Disaster Manual did not include the CDC toolkit with the completed brief assessment, a facility-specific risk assessment using ASHRAE standard #188, a written explanation of the water system flow with identified risk areas, testing protocols and acceptable control ranges, intervention plans when control limits were not met, or documentation of a site log book with dated cleanings, sanitizing, descaling, and inspections. During the walk-through, the facility water system was observed entering the basement and spreading through the kitchen, ice machine, hot water heater, laundry rooms, bathrooms, boiler room, janitor closets with mop hoppers, resident rooms, shower rooms, medication rooms, beauty shop sink, and sprinkler system. The Maintenance Supervisor stated he/she oversaw the Legionella program and did the pathogen testing, and the Administrator stated the program requirements were learned from corporate staff and other maintenance staff. The facility also failed to ensure appropriate hand hygiene during medication administration for Resident #68, Resident #69, and Resident #25. Resident #68 had diabetes mellitus and Resident #69 had diabetes mellitus and epilepsy with intractable status epilepticus; Resident #25 had schizophrenia and moderate intellectual disabilities. During observation of medication passes, an LPN did not wash or sanitize hands before starting, handled a dropped pill from the floor during Resident #68’s pass, continued the medication pass without hand hygiene, and returned to the medication cart without sanitizing hands. The same LPN did not perform hand hygiene before or after the medication passes for Resident #69 and Resident #25. The LPN later stated hand hygiene should be completed before and after each resident during medication administration and after picking up a dropped pill, and another LPN and the DON confirmed that hand hygiene had not been performed appropriately. The facility failed to ensure appropriate hand hygiene during wound care for Resident #2, who had an unspecified foot wound, osteomyelitis, venous or arterial ulcer, and other open lesions on the foot. During wound care observation, the nurse used hand sanitizer and gloves at the start, removed socks and threw them on the floor, cut and removed dressings from both feet, touched the resident’s foot with gloved hands, and repeatedly changed gloves without sanitizing hands between dirty tasks. The nurse also cut calcium alginate with scissors without sanitizing them, wrapped the feet, and did not sanitize hands after placing socks on the resident or wash hands before leaving the room. The resident’s room sink was reported not to work because the faucets had been turned off under the sink, and staff stated they were supposed to wash or sanitize hands before and after wound care and after dirty steps in the process. The facility further failed to complete TB testing according to policy and CDC guidance for eight employees. Several employee files showed first and second step TSTs were performed outside required time frames, some second-step results were not documented, one first-step result was not documented, and some tests were read too early or too late. The DON stated he/she and LPN D were responsible for tracking and completing employee TB testing, that results were supposed to be recorded on the Employee TST form, and that the DON was responsible for auditing and ensuring TB tests were completed according to facility policy.
Missing Acetaminophen Order Parameters
Penalty
Summary
The facility failed to ensure that medication orders containing Acetaminophen included the parameter not to exceed 3 grams in 24 hours from all sources for three sampled residents. Review of the medication records for Resident #78, Resident #6, and Resident #1 showed Acetaminophen orders that did not include this limit. Resident #78 had an order for Acetaminophen 325 mg, two tablets by mouth every four hours as needed for pain or increased body temperature. Resident #6 had an order for Acetaminophen Extra Strength 500 mg, two tablets by mouth every six hours as needed for pain. Resident #1 had an order for Acetaminophen 325 mg, two tablets by mouth every six hours as needed for pain. Facility staff interviews confirmed that the missing parameter should have been included on all Acetaminophen orders. Two LPNs stated that Acetaminophen orders should have had the 3-gram limit and that, if missing, they would have contacted the physician to obtain it, though they were unsure who audited orders for required parameters. The DON stated it was the expectation that all orders containing Acetaminophen include the 3-gram limit, that nurses should ensure the parameter was added when missing, and that it was ultimately the DON's responsibility to ensure compliance. The DON also stated he/she had only been a DON for two months and believed pharmacy audited all medications.
Failure to Ensure Nurse Aides Became CNAs Within Required Timeframe
Penalty
Summary
The facility failed to ensure that 10 Nurse Assistants were certified nursing assistants within four months of hire. Review of an undated hire record sheet showed that NA A, NA B, NA C, NA D, NA E, NA F, NA G, NA H, NA I, and NA J had all been hired, with several of them employed for more than four months without becoming CNAs. The facility census was 75 residents, and a policy on NA training was requested but not received. During interviews, NA A said he/she had started CNA class the prior week, had been hired in February 2025, and that the class was online with nurses observing and completing skill checkoffs; NA A also stated that three other NAs were in the class, including NA F, NA H, and NA J. NA H said he/she had worked at the facility for nine months as a NA, not a CNA, and had only been in the CNA class for a couple of weeks. The Administrator said he/she oversaw staffing and the NA program, knew a NA could only be an NA for four months, and stated that if a NA was not a CNA after four months the person should have been moved to another department or terminated; the Administrator also said some NAs remained longer than four months due to lack of staff. The DON said he/she was not in charge of the NA program, had only been DON for two months, was unaware how many NAs had been NAs longer than four months, and did not know that NAs could only be NAs for four months before becoming certified, moving to another department, or being terminated.
Inconsistent wound assessments and treatment without prior order
Penalty
Summary
The facility failed to ensure consistent and accurate wound assessments by a trained professional and failed to obtain a physician’s order before treating an open wound for one resident with chronic foot wounds, osteomyelitis, and poor circulation. The resident’s record showed long-standing wound care orders for both feet, but the EMR did not contain initial, comprehensive wound assessments by an RN or physician, and there was no documentation showing when the wounds were first identified. The weekly wound tracking forms also showed inconsistent wound descriptions, including wounds being labeled as stasis ulcers, calluses, and unstageable, with no clear documentation of wound onset dates. The weekly wound tracking documentation for the resident showed gaps and inconsistencies over multiple weeks. One week, the right plantar wound was documented as a stasis ulcer and unstageable, while the left plantar area was documented as a callus and unstageable. The following week, a second wound was added to the right plantar area without a first-identification date, and later documentation showed the right plantar wound increasing in size and depth. There was no documentation for a scheduled wound assessment in mid-July, and the nursing notes did not explain why the assessment was not completed. By late July, the documentation changed again, with one wound reclassified from stasis to callus and another wound added to the left foot without a first-identification date. After that, there was no further wound tracking documentation in the EMR. During observation, the resident was seen with dressings to both feet, and the right sock appeared stained as if the wound had seeped. During wound care, an LPN identified black eschar on the right foot, swelling, and open areas, including a new open wound in the mid-arch area. The LPN stated he/she did not know how long the new wound had been present and applied calcium alginate before obtaining a physician order. The LPN also stated weekly wound assessments had not been done since August or earlier, that no specialized wound care training had been received, and that wound assessments were stopped because of overtime concerns and because the resident refused the wound clinic. The DON stated the LPN had been doing the weekly wound assessments, but there were gaps in the assessments and no clear oversight. The DON also stated the nurses were marking weekly skin assessments on the TAR for only the skin they could see because the resident’s feet were usually bandaged.
Delayed fall investigations and outdated care plans after repeated resident falls
Penalty
Summary
The facility failed to complete thorough and timely fall investigations and failed to update the care plans for two residents who had multiple falls. The facility’s policies stated that licensed nurses were to assess falls right after they occurred, complete fall investigation forms for each fall, submit investigation reports to the DON within 24 hours, and that care plans should reflect fall risk and management. Interviews showed staff were unsure who was responsible for completing fall investigations and care plan updates, and the DON stated he/she had not been on top of ensuring the investigations were complete and thorough. One resident had Parkinsonism, tremor, and hallucinations and was documented as cognitively intact on the quarterly MDS. The resident’s care plan identified repeated falls, poor balance, poor safety awareness, and unsteady gait related to medication changes and hallucinations. The resident fell on two occasions, including one unwitnessed fall in which the resident tripped while running down the hall and sustained a laceration above the left eye requiring hospital transfer and five stitches. Another unwitnessed fall occurred when the resident was found on a floor mat and could not explain how the fall happened. The incident audit reports for both falls were created later, and no RCA was completed for either fall. The care plan was not updated to reflect these falls or new interventions by the time of review. The second resident had dementia with severe cognitive impairment and a history of numerous falls. The resident’s care plan, which had not been updated since 12/26/22, identified high fall risk, poor safety awareness, and use of a personal alarm and wheelchair for locomotion. The resident fell twice, once being found beside the bed after trying to get out of bed and once being found on the floor beside the bed after trying to get into bed from a wheelchair. One fall resulted in a small bruise to the forehead, and the resident’s hospice company was notified after both falls. The incident audit reports were created later, no RCA was completed for either fall, and the care plan was not updated to reflect the falls or any new interventions at the time of review.
Improper Positioning During Tube Feeding
Penalty
Summary
The facility failed to ensure appropriate care for a resident with a G-tube. The resident was admitted with cerebral palsy and gastrostomy status, was severely cognitively impaired, fully dependent on staff for repositioning and turning, and received tube feeding for 51% or more of total calories. The care plan dated 7/24/25 stated the resident required tube feeding and that the head of bed (HOB) needed to be elevated to 45 degrees continuously, as tolerated, because the resident slid down in bed. The October 2025 order directed Jevity 1.5 calorie via G-tube at 30 ml/hour for 22 hours a day. Observations showed the tube feeding running while the resident’s HOB was only at 30 degrees and the resident had slid down in bed to about a 20-degree angle on 10/7/25 and again on 10/8/25. Later observations showed the resident slumped to the side and sitting at less than a 30-degree angle while the tube feeding was running, and the resident was also observed less than 30 degrees, and then lying flat in bed on 10/10/25. During interviews, an LPN stated the resident’s HOB needed to be at 30 degrees at all times and that staff needed to monitor the resident frequently because the resident slid down in bed. Other LPNs stated a resident should never lie flat with tube feeding running, and the DON stated the HOB needed to be elevated to at least 30 degrees when tube feeding was running and that staff should have checked the resident more frequently throughout the week.
Medication Error Rate Exceeded Limit Due to Crushed Depakote Tablets
Penalty
Summary
The facility failed to keep the medication error rate below 5 percent for one sampled resident, resulting in 2 medication errors out of 31 observed opportunities and an error rate of 6.45%. The resident involved had diagnoses of epilepsy, intractable epilepsy with status epilepticus, and generalized idiopathic epilepsy. The resident’s October 2025 orders included Depakote delayed-release 125 mg and 500 mg tablets, each to be given by mouth twice daily for seizures, with the 125 mg tablet to be taken with the 500 mg tablet for a total dose of 625 mg. During observation of the medication pass, an LPN removed the resident’s medications, placed all of them into a medication cup, then put them into a plastic bag and crushed all of the medications, including the Depakote delayed-release 125 mg and 500 mg tablets, before mixing the crushed medications into pudding and giving them to the resident. The facility’s policy stated that medications not to be crushed may be opened and sprinkled into pudding or applesauce if clinically appropriate, and Depakote product information stated that Depakote tablets and Depakote ER tablets should be swallowed whole and should not be crushed or chewed. In interviews, the LPNs and DON stated that Depakote tablets could not be crushed and that crushing them could affect how the resident received the dose; the DON also stated the resident’s medication order should state that the medication should not be crushed.
Deficiency in RN Staffing and DON Role Compliance
Penalty
Summary
The facility failed to provide a Registered Nurse (RN) for eight consecutive hours per day, seven days a week, during multiple months spanning from July 2023 to March 2024. This deficiency was identified through observation, interviews, and record reviews, which revealed that there were several days each month without RN coverage for the required hours. Additionally, the Director of Nursing (DON) was found to be serving as the charge nurse on days when the facility census exceeded 60 residents, which is against regulatory requirements. The facility census was noted to be 69 residents during these instances. The facility's staffing issues were further highlighted by the fact that the DON was the only RN available and had to cover shifts as the charge nurse due to the lack of other RNs. The facility had an RN available on a PRN basis, but this individual did not work many hours. The administrator acknowledged the staffing shortfall and indicated efforts were being made to hire more RNs. The absence of a facility RN staffing policy and procedure document prior to the survey exit further compounded the issue.
Inadequate Infection Control and TB Screening in LTC Facility
Penalty
Summary
The facility failed to establish and maintain a comprehensive infection prevention and control program, specifically for Legionella and other water-borne pathogens, as required by CMS guidelines. During inspections, it was observed that the facility lacked a facility-specific risk management plan, a completed CDC toolkit, and a schematic or flowchart of the water system with explanations and assessments of potential stagnation locations. Additionally, there were no documented testing protocols, control measures, or site log books for maintenance activities. Interviews revealed that the Maintenance Supervisor was responsible for the Legionella program but had only received basic education on the requirements. The facility's infection control surveillance policy was outdated, and the infection control book lacked 12 months of tracking and trending data. The logs did not specify whether infections were facility-acquired or present upon admission, nor did they include information on the resolution of infections, the type of infectious organisms, or the utilization of an antibiotic stewardship program. The Director of Nursing, who took over the infection control book in February 2024, was unaware of the full scope of information required for tracking and trending logs. Furthermore, the facility did not have a policy for resident TB testing and screening. Two residents were identified as not having completed TB assessments as required. One resident did not have a two-step TB skin test upon admission, and another resident's last TB assessment was outdated. The Director of Nursing acknowledged the oversight and stated that TB tests should be completed by the admitting charge nurse upon admission, with annual screenings documented in the medical record.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to develop and implement an effective antibiotic stewardship protocol and a system to monitor appropriate antibiotic use for its residents. The facility's existing Antibiotic Stewardship policy, dated 2018, aimed to apply best practices for monitoring antibiotic use, ensuring appropriate prescriptions, and reducing the risk of adverse events from unnecessary or inappropriate antibiotic use. However, the facility's Infection Control tracking log was incomplete, lacking 12 months of infection tracking or antibiotic use logs, with only records from February to August 2024 available. The logs were supposed to document essential details such as the date, room number, resident name, infection type, antibiotic name, order, labs, and organism, but they did not include lab results or logs indicating signs or symptoms of infections for antibiotic use. During an interview, the Director of Nursing, who had been responsible for the Infection Control tracking log and antibiotic stewardship program since February 2024, admitted to entering prescribed antibiotics on the log along with the resident's room number and type of infection. However, the Director could not locate lab or X-ray results in the tracking book, and the book did not include signs or symptoms of infections being treated with antibiotics. This lack of documentation and monitoring indicates a failure to adhere to the facility's own antibiotic stewardship policy, which included protocols for common infections and criteria for initiating antibiotic use.
Failure to Designate Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a qualified individual with the required primary professional training as the Infection Preventionist (IP) for its Infection Prevention Control Program. The Director of Nursing (DON) was intended to assume the role of the IP but had not completed any certification classes necessary for the position. Additionally, the facility did not have a policy outlining the required primary professional training for the IP role. The Administrator, who held an IP certificate and dedicated a few hours weekly to infection control duties, had a degree in Social Work, which is not among the approved primary professional medical trainings. The previous IP had left the facility, and the current DON was expected to become the primary IP without having completed the necessary training.
Deficient Pressure Ulcer Care and Documentation
Penalty
Summary
The facility failed to ensure proper pressure ulcer care and prevention for a resident with an unstageable pressure ulcer. The facility did not have a policy or physician's order addressing the settings for a low air loss (LAL) mattress, which is crucial for distributing the patient's body weight to prevent and treat pressure wounds. The resident's care plan was not updated to reflect the current stage of the pressure ulcer, and there was no documentation of the LAL mattress settings in the resident's treatment administration record (TAR). The LAL mattress was set incorrectly at 350 pounds, despite the resident weighing significantly less. The facility also failed to complete weekly wound/skin assessments with detailed descriptions, measurements, and accurate staging of the pressure ulcer. The documentation inconsistently identified the type of wound, often incorrectly labeling it as a stasis ulcer, and failed to include comprehensive details about the wound bed, drainage, odor, and measurements. There were significant gaps in the documentation of wound assessments, with no assessments completed between certain dates, and the resident's care plan did not mention the unstageable pressure ulcer or the LAL mattress settings. Interviews with facility staff, including the wound nurse, LPN, MDS/Care Plan Coordinator, and DON, revealed a lack of awareness and adherence to proper procedures for pressure ulcer management. The staff did not monitor the LAL mattress settings, and there was no physician's order for the LAL mattress. The care plan was not individualized to include the current stage of the resident's pressure ulcer, and the facility's pressure ulcer documentation lacked essential information. The DON acknowledged that the documentation should have included detailed descriptions of the wound, and the care plan should have been updated to reflect the resident's current condition.
Deficiency in Feeding Tube Management and Documentation
Penalty
Summary
The facility failed to adhere to professional standards for verifying the correct placement of gastrostomy (G-tube) feeding tubes, as evidenced by the lack of a comprehensive tube feeding policy. The policy did not instruct licensed nursing staff to measure and document the length of the feeding tube, nor did it provide guidance on verifying tube placement using current professional standards. Instead, outdated methods such as auscultation and aspiration were used, which are considered unreliable. This deficiency was observed in the care of a resident who was receiving tube feeding, where the facility did not ensure the physician's order was correct or that the tube feeding was infused according to the order. The resident in question had a diagnosis of cerebral palsy and was severely cognitively impaired, relying on a feeding tube for more than 51% of their caloric intake. Observations revealed that the resident's tube feeding was not consistently infused as ordered, with instances where the feeding pump was not running. The Director of Nursing (DON) was observed administering water through the G-tube without first verifying its placement, citing a lack of a stethoscope as the reason for not performing the check. The DON admitted to being unaware of the professional standard requiring the measurement and documentation of the tube's length. Interviews with facility staff, including a Licensed Practical Nurse (LPN) and the MDS Care Plan Coordinator, highlighted inconsistencies in the understanding and implementation of tube feeding protocols. The LPN acknowledged that the physician's order in the resident's electronic medical record was incorrect and needed correction. The MDS Care Plan Coordinator confirmed that aspiration was the only method known for checking tube placement and that this method was not included in the resident's care plan. These lapses in protocol and documentation contributed to the deficiency in providing appropriate care for the resident with a feeding tube.
Failure to Provide Trauma Informed Care for Residents with PTSD
Penalty
Summary
The facility failed to provide Trauma Informed Care (TIC) assessment and care planning for two residents diagnosed with Post Traumatic Stress Disorder (PTSD). The facility's policy required a self-assessment and trauma questionnaire to be completed before admission, with updates every three years, and the use of the Brief Trauma Questionnaire for screening. However, for Resident #18, there was no documentation of the Brief Trauma Questionnaire, PTSD Checklist, or Psychological Well-Being evaluation in the medical records. The resident's care plan lacked interventions specific to TIC needs, such as identifying triggers and steps to mitigate them. Resident #18 had a history of extensive sexual abuse and other psychiatric diagnoses, including major depression and anxiety. Despite being cognitively intact and socially isolated, the resident's care plan did not address PTSD needs or include strategies to prevent triggers. Interviews with staff revealed a lack of awareness and training regarding the resident's PTSD diagnosis and TIC principles. The Social Services Director and other staff members were unaware of the resident's triggers and had not conducted a TIC assessment. Similarly, Resident #53's care plan did not include interventions specific to TIC needs, and there was no documentation of the required trauma assessments. The resident was also diagnosed with PTSD, anxiety, depression, and a personality disorder. The facility's failure to incorporate TIC assessments and care planning into the residents' care plans resulted in a deficiency in providing trauma-informed and culturally competent care.
Failure to Implement Gradual Dose Reduction for Psychotropic Medications
Penalty
Summary
The facility failed to ensure timely physician response to a pharmacist's recommendation for gradual dose reduction (GDR) of psychotropic medications for a resident. The resident, who was severely cognitively impaired and had symptoms of depression, hallucinations, and diagnoses including anxiety disorder, depression, manic depression, and schizophrenia, was receiving multiple psychotropic medications. The consultant pharmacist recommended potential GDRs for several medications, including Escitalopram, Olanzapine, Trazodone, and Haloperidol. However, there was no documented response from the physician regarding these recommendations, and a GDR had not been attempted or documented as clinically contraindicated. The Director of Nursing (DON) was responsible for reviewing pharmacy recommendations and implementing GDRs. The DON took over this duty after discovering that pharmacy recommendations were not being addressed. The consultant pharmacist visited the facility monthly and emailed recommendations to the DON, who then contacted the physician. If the physician agreed to the recommendation, changes were made in the resident's electronic medical record (EMR). If the physician disagreed, a reason should have been documented. In this case, the physician did not provide a reason for not following the pharmacist's recommendation, and the DON did not follow up to obtain one.
Failure to Post Daily Staffing Information
Penalty
Summary
The facility failed to ensure that daily staffing information was posted correctly at the beginning of each shift, which could potentially affect all residents. The facility census was 69 residents. Observations on multiple days showed that the required staffing information, including staff titles and total hours worked, was not posted on the second or third floors. During an interview, the MDS Coordinator indicated that the staffing information was posted by the employee time clock on the first floor, which was not visible to residents on the upper floors. The Coordinator was unaware of who was responsible for posting the information but expected it to be available for residents and visitors. The DON stated that the BOM was responsible for posting the staffing information outside their office daily and expected it to be visible to all residents and visitors on the second and third floors.
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 56 citations issued within 25 miles in the last 12 months — 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 Warrensburg
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Country Club Rehab And Healthcare Center | 1 mi | ★★★★★ | 0 | 0 |
| Ridge Crest Nursing Center | 1 mi | ★★★★★ | 16 | 0 |
| Warrensburg Manor Care Center | 1.1 mi | ★★★★★ | 0 | 0 |
| Holden Manor Health & Rehabilitation | 14.4 mi | ★★★★★ | 1 | 0 |
| Lutheran Nursing Home | 17.9 mi | ★★★★★ | 4 | 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.