Citations in Kansas
Comprehensive analysis of citations, statistics, and compliance trends for long-term care facilities in Kansas.
Statistics for Kansas (Last 12 Months)
Financial Impact (Last 12 Months)
Latest Citations in Kansas
Surveyors found that the facility failed to maintain sanitary food storage, handling, and dishwashing practices in the kitchen. Clean dishes were stored upright instead of inverted, and numerous food items in coolers, freezer, pantry, and spice racks were undated, missing the year, had unreadable dates, or showed visible mold, while some bags and containers were left open or unsealed. A dietary staff member handled ready-to-eat foods such as bread and butter with bare hands and repeatedly washed hands with water only, without soap or sanitizer, while preparing pureed meals for a resident. The low-heat dish machine repeatedly operated below the facility’s stated minimum wash temperature, as documented on the temperature log. These practices were inconsistent with the facility’s own food storage policy and staff’s stated expectations for glove use, labeling, sealing of food, dish storage, and dishwashing temperatures.
The facility did not employ a full-time Certified Dietary Manager (CDM) as required by its own Nutritional Services Policy, despite serving meals to 31 residents. A dietary staff member without CDM credentials was observed overseeing meal preparation, and both this staff member and an administrative nurse confirmed that the staff member was not certified, although enrolled in CDM classes. The policy specified that a CDM must oversee key functions such as menu planning, diet and diet manual with nutritional evaluations, office procedures for notifying the RD of new elders, food production, and food service, but no certified individual was fulfilling these responsibilities.
Surveyors found that the facility failed to follow professional standards for food storage and temperature monitoring. A freezer had significant ice buildup, and a refrigerator contained unlabeled, undated sliced cheese. Temperature logs for multiple freezers and refrigerators were incomplete over several days, despite policy requiring routine monitoring and documentation. The ice machine area contained extraneous items, including a plastic lid, a metal object on the floor, and a cup on the drain. In dry storage, several open food items, including pasta, noodles, gelatin, and pancake mix, were undated, unlabeled, or unsealed. Dietary staff confirmed these conditions, and the Dietary Manager later described expectations that all food be labeled, dated, and properly sealed per facility policy.
Surveyors found that staff did not consistently follow EBP, hand hygiene, and clean laundry handling practices. During tracheostomy care for a resident, a nurse wore gloves and a mask but did not don a gown or change gloves before placing clean gauze and the trach cannula. In a separate case, after completing wound care for another resident, the same nurse manipulated a suprapubic catheter tubing while still holding wound supplies and then left the room without performing hand hygiene. Additionally, a housekeeping/laundry staff member removed residents’ personal items from a covered cart and carried them over the shoulder between halls without keeping the items covered. These actions did not follow facility policies requiring targeted gown and glove use for high-contact care, proper hand hygiene around invasive devices and dressings, and keeping laundry carts covered between rooms.
The facility failed to coordinate hospice services within the care plans for two residents receiving hospice. Both residents had severe cognitive impairment and extensive ADL needs, and their MDS assessments documented hospice care. Their care plans included general directions about ADL assistance, pain monitoring, and consulting with hospice or the physician, but omitted key hospice-specific details such as hospice contact information, visit schedules, services to be provided, and what supplies, equipment, and medications hospice would furnish. Clinical record review and interviews with an administrative nurse confirmed that there was no documented coordination between hospice and facility care plans, contrary to the facility’s hospice policy requiring an interdisciplinary plan integrating hospice and facility services.
A resident receiving wound and catheter care was assisted by an RN and a CNA who donned gowns, N95 masks, and gloves before entering the room. After perineal and catheter care, the RN did not change gloves or perform hand hygiene and continued to separate the resident’s labia, adjust clothing, handle the bed pad, reposition the resident, and operate the bed controls with the same soiled gloves. This practice conflicted with the facility’s infection control policy, which requires removal of soiled gloves and handwashing when moving from dirty to clean tasks and after contact with potentially infectious material.
A resident with diabetes, heart failure, muscle weakness, severe cognitive impairment, incontinence, and limited mobility was identified as at risk for pressure ulcers, with care plans calling for turning/repositioning, use of a pressure-reducing device, and extensive staff assistance for ADLs. Despite these documented risks and interventions, the resident, who preferred to remain in a recliner or wheelchair and became less mobile after a foot fracture requiring a walking boot, developed a facility-acquired Stage 2 pressure ulcer on the buttocks. Wound assessments showed the ulcer’s presence and progression over time, indicating that timely and effective preventive measures were not implemented in accordance with the facility’s wound assessment and prevention policy.
Surveyors found expired acetaminophen 650 mg suppository floor stock on the North Hall medication cart, despite facility policy requiring proper labeling, storage, and removal of expired drugs. A CMA and an administrative nurse each confirmed that medication aides or nurses were responsible for checking the cart and discarding expired medications, but the expired suppositories remained available on the cart.
A resident with hemiparesis, chronic osteomyelitis, and intervertebral disc disorder with radiculopathy experienced a fall in his room, was found on the floor near a heater with pain and bruising, and was later confirmed by mobile X-ray to have a nondisplaced fracture of the left superior pubic ramus. Despite this, the subsequent quarterly MDS documented no falls since the prior assessment and did not code the event as a fall with major injury, even though the care plan and progress notes described the fall and resulting fracture. An administrative nurse later acknowledged that the falls section of the MDS had been coded in error, contrary to facility policy and RAI manual requirements for accurate resident assessment.
A resident with severe morbid obesity, vascular dementia, anxiety, and a history of falls, but intact cognition per BIMS, was repeatedly assisted in a wheelchair by staff without foot pedals in place. On multiple observed occasions, staff pushed and turned the resident in the wheelchair while the resident held his feet off the floor and a sock was seen dragging on the floor. Interviews showed staff uncertainty and inconsistency regarding the requirement for foot pedals when assisting the resident, despite the resident’s documented fall risk and a facility falls policy requiring interventions to reduce fall risk.
Unsanitary Food Storage, Handling, and Dishwashing Practices in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to maintain sanitary conditions for food storage and preparation in the kitchen. During an initial kitchen tour, they observed multiple clean containers and plates on the drying rack not inverted, leaving eating surfaces exposed. Numerous food items in the kitchen cooler, walk-in cooler, freezer, pantry, and spice rack were either undated, missing the year, had unreadable dates, or were past labeled use-by dates. Examples included cheese and ham slices with only month and day, multiple large containers of sauces, dressings, olives, cherries with visible black mold on the rim and lid, parmesan cheese, syrups, soy sauce, wing sauce, and green beans all lacking complete or legible dating. Additional findings included rusted and peeling cooler racks, open and unsealed bags of frozen foods and pantry items, and a rice bin with a handwritten prep date missing the year. Further observations showed improper food handling and hand hygiene practices by dietary staff. One dietary staff member handled ready-to-eat foods, including butter and bread for toast, with bare hands and then placed the toast on a tray for a resident. On another occasion, a partially wrapped package of cheese slices in the cooler was found without any date. The same dietary staff member was observed washing hands under running water without using soap or sanitizer on three separate occasions while pureeing food for lunch. The facility did not provide a hand hygiene policy specific to dietary staff when requested. Surveyors also reviewed the operation of the low-heat Ecolab dishwasher and its temperature logs. At the time of observation, the wash temperature was 102°F, and the April temperature log showed multiple days with wash temperatures below the documented minimum of 120°F at which the supervisor should be notified. Administrative and dietary staff later confirmed that gloves should be worn when handling ready-to-eat foods, all stored food should be sealed and labeled with month, day, and year, dishes should be inverted, and the dishwasher wash cycle should be at least 120°F. The facility’s existing Food Storage policy required staff to label all food items with the name and date opened or use-by date and to discard food past expiration, but survey findings showed these practices were not consistently followed in the kitchen.
Lack of Certified Dietary Manager Overseeing Food and Nutrition Services
Penalty
Summary
The facility failed to employ a full-time certified dietary manager (CDM) to oversee food and nutrition services for 31 residents receiving meals from the facility kitchen. On one observed noon meal, the menu consisted of shrimp, cornbread, cooked sliced squash, rice, and yellow cake with chocolate frosting, and dietary staff member BB was observed overseeing preparation of this meal in the kitchen. During an interview, dietary staff BB confirmed she was not a CDM, stating she had enrolled in but not completed the certification classes. Administrative Nurse D also verified that dietary staff BB did not have dietary manager certification, although she had started the dietary certification classes. The facility’s Nutritional Services Policy, revised 01/21/26, documented that a certified dietary manager would oversee all kitchen procedures, including menu planning, diets and the diet manual with nutritional evaluations, office procedures related to notifying the Registered Dietitian of new elders, food production, and food service, but no such certified individual was in place at the time of the survey.
Failure to Properly Label, Store, and Monitor Food and Equipment Temperatures
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage, distribution, and service practices based on observations, record review, and staff interviews. In the kitchen, a white upright freezer had approximately one-quarter inch of ice buildup along the inside and shelves, and the kitchen refrigerator contained a plastic bag of sliced yellow cheese that was unlabeled and undated. Review of March temperature logs showed missing morning and evening temperature documentation for multiple units, including a chest freezer in dry storage on numerous dates, a white stand-up freezer on several dates, a double-door refrigerator on several dates, and a single-door refrigerator on multiple dates. April logs also lacked documentation of readings for a double-door freezer on specified dates. The facility’s policies required that frozen foods be stored at 0 to -10°F, produce at 38-44°F, dairy at 35-40°F, and that temperature logs be completed and monitored by the Certified Dietary Manager or designee. Additional observations showed sanitation and labeling issues in and around the kitchen and dry storage areas. The ice machine between the kitchen and storage room had a plastic lid and a metal object on the floor behind it, and a plastic green drinking cup sitting on top of the drain underneath it. Eight 15.5-lb plastic jugs of used cooking grease were observed with numerous grayish-black substances on their tops. In dry storage, surveyors found an approximately one-quarter full 5-lb package of undated pasta Labello egg noodles, an approximately one-quarter full 4.5-lb package of unlabeled, undated, unsealed noodles, approximately three-quarters of a full package of undated strawberry gelatin, and an approximately three-quarters full bag of unsealed buttermilk pancake mix. A dietary staff member verified these findings during the survey, and the Dietary Manager later stated that staff were expected to label and date all food placed in dry storage, refrigerators, or freezers when received and when opened, and ensure items were sealed, labeled, and dated with the open date, as outlined in the facility’s written policies.
Failure to Follow Enhanced Barrier Precautions, Hand Hygiene, and Laundry Handling Practices
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective infection prevention and control program, specifically related to Enhanced Barrier Precautions (EBP), hand hygiene, and handling of clean laundry. During tracheostomy care for Resident 2, a licensed nurse performed hand hygiene, donned gloves, and wore a mask but did not don a gown as required under EBP and did not change gloves before placing clean gauze or the tracheostomy cannula. In a separate wound care observation for Resident 6, the same nurse performed hand hygiene and applied a gown and gloves before care, but after completing the wound care and while holding gauze and wound cleanser, the nurse inspected and manipulated the resident’s suprapubic catheter tubing and then left the room without performing hand hygiene. Additional deficiencies were observed in the handling of clean laundry. A housekeeping/laundry staff member placed a covered cart with residents’ personal items in one hall, then removed items from the cart and carried them over the shoulder to another hall without using the cart and without keeping the items covered between rooms. Interviews with nursing and administrative staff confirmed that wound care supplies should be kept in residents’ rooms or bagged and taken to the wound nurse, that hand sanitizing should be performed before and after wound care and after contact with catheters or tubing, and that staff are expected to wear gown, gloves, and mask at minimum for EBP. The housekeeping supervisor also stated that laundry staff are expected to keep the cart covered between rooms. These practices did not align with the facility’s written policies on EBP and hand hygiene, which require targeted gown and glove use during high-contact care and hand cleansing before and after resident contact, after contact with blood or body fluids, after removing PPE, and before procedures involving invasive devices or dressing care.
Failure to Coordinate Hospice Services in Resident Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to develop and maintain a coordinated hospice plan of care that integrated hospice services with facility services for two residents receiving hospice. For one resident with Alzheimer’s disease, CAD, and atrial fibrillation, the Significant Change MDS documented severely impaired cognition and extensive assistance needs for bed mobility and transfers, and indicated the resident was receiving hospice services. The resident’s care plan noted a terminal prognosis due to Alzheimer’s, directed staff to adjust ADL care, consult the physician for hospice care in the facility, and monitor and treat pain, but it did not include instructions on hospice services such as hospice staff visit schedules, supplies, medical equipment, or medications covered by hospice. The clinical record showed the resident had been admitted to hospice care months earlier, yet there was no documented evidence of coordination of care between hospice and the facility. For the second resident, diagnosed with PVD, DM, HTN, and atherosclerotic heart disease, the Significant Change MDS showed severe cognitive impairment with a BIMS score of two and dependence on staff for most ADLs, and documented that the resident received hospice services. The resident’s care plan recorded admission to hospice and directed staff to adjust ADL provision, encourage participation as desired, assess coping, respect wishes, and consult with the physician and hospice for continuing hospice care, as well as monitor for pain and notify the physician and hospice for breakthrough pain. However, the care plan lacked a hospice contact number, information on what supplies, equipment, and medications hospice would provide, and details on when hospice staff would be in the building and what care they would deliver. Observations and staff interviews confirmed these omissions. One resident was observed in bed receiving eye drops from a CMA, and during record review, the Administrative Nurse acknowledged that the facility care plan lacked specific information coordinating with the hospice care plan. For the second resident, the Administrative Nurse verified that the care plan did not contain information regarding hospice visits, phone numbers, or medical supplies provided by hospice, and stated that such information should be on the resident’s care plan. These findings were inconsistent with the facility’s Hospice Services policy, which required an interdisciplinary care plan integrating facility and hospice services, including coordination of services and supplies provided by the hospice provider.
Failure to Perform Hand Hygiene and Change Gloves Between Perineal and Other Care Tasks
Penalty
Summary
Surveyors identified a failure to follow the facility’s infection control policy for hand hygiene and glove use during care for Resident 6. On 04/15/26 at 10:21 AM, the resident was observed resting in bed when a licensed nurse and a CNA donned gowns, N95 masks, and gloves before entering the room to assess a wound on the resident’s buttocks and provide catheter care. The resident was uncovered and noted to have no incontinent brief on. The CNA separated the resident’s buttocks and identified an open area approximately 0.3 cm long by 0.2 cm wide, then performed catheter care by cleansing the tubing from the insertion site down with a wet soapy washcloth followed by a dry washcloth. After this care, the licensed nurse assisted in repositioning the resident and, without changing gloves or performing hand hygiene, separated the resident’s labia, then used the same soiled gloves to pull down the resident’s front blouse, place hands on the cloth bed pad to help pull the resident up in bed, pull the sheet and blanket over the resident, place the bed control in the resident’s hand, and adjust the head of the bed. The nurse then removed and discarded the gloves, gown, and mask in a trash can. The nurse confirmed she had not changed gloves after assessing the resident’s labia and acknowledged she should have. The facility’s Infection Control Policy, revised 01/19/26, directed staff to remove soiled gloves, wash hands, and change gloves after contact with infectious material and before leaving the resident’s environment, and to wash hands immediately with antimicrobial soap. An administrative nurse stated she would expect staff to change gloves and wash hands when providing care, especially when moving from dirty to clean tasks.
Failure to Implement Timely Interventions to Prevent Facility-Acquired Pressure Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to initiate timely and adequate interventions to prevent the development and progression of a pressure ulcer for Resident 27, who was identified as at risk for pressure ulcer development. The resident had multiple diagnoses including diabetes mellitus, osteoarthritis, heart failure, and muscle weakness, and had a BIMS score of five indicating severely impaired cognition. Assessments documented that the resident required extensive assistance of one to two staff for bed mobility, personal hygiene, dressing, repositioning, and transfers, and that she had a urinary catheter for constant urinary retention and incontinence. The MDS and care plans identified the resident as at risk for skin impairment, with a history of refusing to lie down to relieve pressure from the buttocks, and indicated she was on a turning/repositioning program with nutritional or hydration interventions and a pressure-reducing device in her chair. A Braden Scale score of 16 further indicated risk for pressure ulcer development. Despite these identified risks and care plan directives, the resident developed a facility-acquired Stage 2 pressure ulcer on the left buttocks. Weekly wound assessments documented the presence and progression of an open area on the left buttocks, with measurements changing over time, including a lateral opening measuring 2.0 cm by 1.0 cm and later a left inner buttocks wound measuring 3.0 cm by 2.0 cm by 0.5 cm depth, and then 2.0 cm by 3.5 cm by 0.8 cm depth. The record noted that the resident became less mobile after sustaining a left 5th metatarsal fracture requiring a walking boot, and that she was incontinent and preferred to sit in a recliner and wheelchair rather than sleep in bed. The facility’s own Wound Assessment, Prevention and Treatment policy required timely skin assessments, Braden evaluations, and immediate implementation of plans to reduce pressure ulcer risk, but the development of a facility-acquired pressure ulcer under these known risk conditions demonstrated that timely preventive interventions were not effectively implemented.
Expired Floor Stock Medication Found on Medication Cart
Penalty
Summary
Surveyors identified a deficiency in the facility’s management of medication storage when, during observation of the North Hall medication cart on 04/13/2026 at 08:10 AM, they found four acetaminophen 650 mg suppositories with an expiration date of 3/2026 still present as floor stock. Certified Medication Aide R confirmed at 08:15 AM that medication aides or nurses were responsible for discarding expired medications. On 04/15/2026 at 02:30 PM, Administrative Nurse E also verified that medication aides or nurses were expected to check the medication cart and discard expired medications. The facility’s Medication Labeling and Storage policy, dated 01/22/2026, required that medications be labeled and stored in accordance with facility requirements and State and Federal laws, and that floor stock medications be kept in the original manufacturer’s container with the expiration date and lot number clearly evident, yet the expired acetaminophen suppositories remained on the cart. No specific residents or their medical histories were mentioned in relation to this deficiency, and the findings were limited to the presence of expired stock medication on the North Hall medication cart and staff acknowledgments of their responsibility to remove such medications.
Inaccurate MDS Coding of Fall With Major Injury
Penalty
Summary
The deficiency involves the facility’s failure to accurately complete the Minimum Data Set (MDS) assessment for Resident 13, resulting in an incorrect coding of the resident’s fall history and injury status. Resident 13’s electronic medical record documented multiple diagnoses, including hemiparesis/hemiplegia, chronic osteomyelitis, and intervertebral disc disorder with radiculopathy. The quarterly MDS dated 03/24/26 recorded a Brief Interview for Mental Status (BIMS) score of 15, indicated the resident required supervision for walking 10 feet and partial assistance for walking 50 feet, and documented that the resident had no falls since the previous MDS assessment. However, this conflicted with clinical documentation and the resident’s care plan and progress notes. On 01/16/26, progress notes showed that staff responded to the resident’s call light and found him on the floor next to his heater, lying on boxes, papers, and his bedside table. The resident complained of back and left hip pain, had swelling behind his left ear from hitting the heater, redness on his left cheek, and reported tenderness with weight-bearing on his leg. A mobile X-ray later confirmed a nondisplaced fracture of the left superior pubic ramus, and the provider assessed the resident the same day. The care plan documented that the resident continued to act independently despite education to use the call light, and the resident later reported to therapy staff that he had falls and was working to get stronger after his last fall. During interviews, an administrative nurse acknowledged that the resident had a fall resulting in a hip fracture that should have been coded on the MDS as a fall with major injury, and that the falls section of the MDS had been coded in error, contrary to the facility’s policy to complete the MDS according to federal regulations and the RAI manual.
Failure to Use Wheelchair Foot Pedals When Assisting a Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide an environment free of accident hazards by not ensuring the use of wheelchair foot pedals when staff assisted a resident in a wheelchair. The resident had diagnoses including severe morbid obesity, vascular dementia, anxiety, and noncompliance, and had a BIMS score of 15 on multiple MDS assessments, indicating intact cognition. The resident’s assessments and Falls Care Area Assessment documented a history of falls within the previous months and identified the resident as being at risk for falls. The care plan documented that the resident was at risk for falls, had experienced a fall, and that his back locked up at times requiring the use of a wheelchair. On one observed occasion, a CNA pushed the resident in a wheelchair without foot pedals attached as he was brought from outside smoking back to his room, during which the resident crossed and held his feet off the floor. On another observed occasion, a nurse turned the resident in his wheelchair and assisted him to the dining room without foot pedals, during which the resident’s sock was half off and dragged on the floor, and the resident again held his foot off the floor. During interviews, one nurse expressed uncertainty about whether the resident should be assisted in the wheelchair without foot pedals, while a CMA stated the resident used foot pedals when being assisted but not when self-propelling. Administrative nursing staff confirmed that staff should not assist the resident in the wheelchair without foot pedals. The facility’s falls policy stated that residents would be assessed for fall risks and interventions implemented to reduce those risks.
Some of the Latest Corrective Actions taken by Facilities in Kansas
- Re-educated all facility staff on abuse, neglect, and exploitation (ANE) to reinforce abuse-prevention expectations (J - F0600 - KS)
- Implemented a facility visitor sign-in sheet to improve oversight of individuals entering the building (J - F0600 - KS)
- Implemented a specific visitor log for the affected resident (R1) to track and monitor visitors (J - F0600 - KS)
Failure to Prevent Armed Workplace Violence Between CNAs on Resident Unit
Penalty
Summary
The deficiency involves the facility’s failure to keep the environment free from accident hazards and to provide adequate supervision to prevent accidents, specifically by failing to prevent two CNAs from bringing firearms into the building and engaging in gunfire on a resident unit. On the night of the incident, one CNA (CNA M) walked down the Northeast (NE) corridor, unlocked an exit door, then returned toward the nurses’ station. He reached into his jacket, turned toward the dining room where another CNA (CNA N) was located, and fired multiple shots into the dining room. Video surveillance reviewed by administrative staff showed this sequence of events, including CNA M unlocking the NE corridor door, returning toward the nurses’ station, drawing a gun from his jacket, firing into the dining room, and then fleeing out the NE corridor door. In response to the gunfire from CNA M, CNA N returned an unknown number of rounds down the East Hall, where nine residents resided. A bullet grazed the wall near the room of one resident (R2), leaving a four- to six-inch graze mark, and a bullet, possibly the same one, struck the doorframe of another resident’s room (R1). Subsequent observation of the East Hall revealed a round indentation on the lower part of R1’s doorframe and a graze mark on the wall near R2’s room. In the dining room across from the East Hall, there were two bullet holes in the window and two to three bullet holes in the wall. Staff on duty reported hearing gunshots and screams, seeing smoke and shell casings near the nurses’ station, and then moving to call 911 and check on residents. Residents described being awakened and startled by the gunfire. R1, seated in a wheelchair in his room, reported initially thinking the sounds were pots and pans clanging, then realizing they were three to four shots, one of which hit his doorframe; he thought the shooter might be coming into his room for him. R2, also in a wheelchair in his room, stated that the gunshots startled him awake and that he was scared for a few seconds. Staff interviews revealed that earlier in the shift, CNA N felt uneasy about CNA M and went out to his car to retrieve his gun, which he then brought into the facility without reporting his concern to anyone. Another nurse (LN I) and a CNA (CNA O) described an escalating verbal argument between CNA M and CNA N in the dining area, including demeaning and vulgar comments, with CNA M pacing and attempting to leave while CNA N continued to pull him back into the conversation, before CNA M walked down the NE hall, returned, and began firing. The facility’s employee handbook, in effect at the time, prohibited acts or threats of violence and the possession of weapons of any kind on the property, but both CNAs nonetheless possessed guns inside the facility and engaged in gunfire on the East unit, placing residents in immediate jeopardy.
Removal Plan
- The facility began staff education on workplace violence, reporting protocols, security, anti-harassment and anti-retaliation protections, and technology and social media controls (education ongoing).
- The facility contracted with a security agency for a nighttime security guard.
- The facility notified the residents' representatives of the incident.
- The facility had a psychologist visit with residents possibly affected by the incident.
Failure to Protect Cognitively Impaired Resident From Suspected Sexual and Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively impaired resident from abuse and to respond appropriately to injuries of unknown origin, including bruising and vaginal bleeding. The resident had hemiplegia and severe cognitive impairment, required extensive assistance with ADLs, and depended on staff for care. Her care plan noted participation in activities but did not address the involvement of her son, identified as her representative and alleged perpetrator (AP), in her care, and listed another son as DPOA. Prior skin and weekly assessments documented no bruising or vaginal bleeding up to mid-March, and the last weekly skin assessment before the incident showed no bruises or open lesions. On the night in question, a CNA observed significant bruising on the resident’s right leg around late evening and reported it to the charge nurse (LN G). LN G assessed the bruising, determined it was probably from the wheelchair or therapy, and did not report it as an injury of unknown origin to administration. Later that night, around early morning, the same CNA observed bright red blood in the resident’s brief and vaginal area, along with what he thought might be clotted blood or a sore, and again reported this to LN G. LN G, relying on the AP’s report that the resident had been scratching and might have a yeast infection, instructed the CNA to apply antifungal powder or cream without personally assessing the vaginal area and without reporting the bleeding and possible injury to administration or the provider. During this time, the AP remained in the room with the resident, often with the door closed, and staff had previously reported feeling awkward and uncomfortable performing peri care while he was present. On the following day, a day-shift CNA providing peri care observed dried blood on the resident’s labia and vaginal area and notified another nurse (LN I), who noted dried blood and bruising on the right hip and leg and reported this to the charge nurse (LN H). Despite this, an earlier skilled evaluation by LN H that same day inaccurately documented no skin issues. Later that afternoon, a two-nurse assessment by LN H and LN I revealed a large bruise on the right hip and leg resembling the shape of a hand, extensive maroon/purple bruising and petechiae around and into the vagina, small lacerations and shearing injuries to the labia, and bruising on the lower abdomen and thighs. The resident displayed increased anxiety and repeatedly said “Oh God” during the assessment and was unable to explain how the injuries occurred. Multiple staff statements documented that the AP stayed in the room almost continuously with the door closed, remained present during intimate cares, acted nervous and fidgety, sometimes took over incontinent care, and left the building frantically after the injuries were discovered. The facility’s failure to recognize and report the initial bruising and vaginal bleeding as potential abuse, to promptly assess the resident, and to remove or restrict the AP allowed him to remain alone with the resident for many hours while her injuries progressed, resulting in a finding of immediate jeopardy. Additional documentation from the hospital and law enforcement supported concerns of sexual assault. The hospital record noted bleeding in the vaginal area with signs of injury, scattered bruises on the extremities, hips, and thighs, and documented that staff had concern for possible sexual assault. Hospital staff also recorded that the resident became agitated and yelled statements such as “Noooo why would a man do that” when her genitalia were cleaned, and that access to her hospital records was blocked from the patient portal due to reasonable belief that sharing them could result in harm to her life or physical safety. Witness statements from CNAs described the resident asking, “why she let that man do that” and saying “Son, why would you do this to me?” during care, though it was not documented that these statements were reported at the time. Law enforcement officers and the SANE examiner later described the resident’s wounds as among the worst they had seen and indicated that a warrant was required for the SANE exam because the AP, listed as legal representative, had left and could not be contacted. Throughout the period leading up to the discovery of the full extent of the injuries, staff had observed the AP’s constant presence, closed-door behavior, and controlling involvement in care, and some staff had reported discomfort and concerns to charge nurses, but these concerns were not acted upon prior to the incident. The facility’s abuse, neglect, and exploitation policy required prevention of all types of abuse and ensuring resident safety regarding visitors and representatives, but staff did not implement protective measures in response to the AP’s behavior or the resident’s injuries and statements. The failure to promptly recognize, assess, and report bruising and vaginal bleeding of unknown origin, combined with allowing the AP to remain alone with the resident with the door closed and to participate in intimate care despite staff discomfort and the resident’s cognitive impairment, led to the determination that the resident was not kept free from abuse and experienced preventable and intentional physical and sexual abuse and psychosocial trauma. The delay of approximately 16 hours from the initial report of bruising of unknown origin to notification of administrative staff, and the inaccurate documentation of no skin issues by LN H earlier on the day the injuries were identified, were key factors in the deficiency finding.
Removal Plan
- Re-education for abuse, neglect and exploitation (ANE) for all facility staff.
- Implemented a protection plan for Resident 1 (R1) requiring all cares be performed with two staff.
- Implemented a protection plan for R1 requiring the room door to remain open unless private cares were being provided.
- Implemented a protection plan for R1 requiring that if the alleged perpetrator (AP) entered the facility, law enforcement (LE) would be notified immediately.
- Implemented a protection plan for R1 requiring a staff member to go to R1's room and remain with her until law enforcement arrived if the alleged perpetrator entered the facility.
- Implemented a sign-in sheet for all visitors to the facility.
- Implemented a specific visitor log for R1.
Failure to Follow Mechanical Soft Diet Orders Resulting in Choking Episode
Penalty
Summary
The deficiency involves the facility’s failure to provide a resident with food in the physician-ordered mechanical soft, ground meat form. The resident had diagnoses of dysphagia, oropharyngeal phase dysphagia, and Alzheimer’s disease, with a BIMS score of four indicating severe cognitive impairment. Her MDS and CAAs documented that she coughed or choked during meals or when swallowing medications and that she required a mechanically altered diet. The care plan and EMR orders specified a regular diet with mechanical soft texture, ground meat with gravy or sauce (no dry meat), and multiple restrictions including no soft tortilla shells, no salad, no raw onions, no raw vegetables, and tortilla chips to be crushed or broken. An intervention also directed staff to cut up her food and remind her to take only one bite at a time. Despite these documented needs and orders, on the day of the incident the resident was served a whole chicken strip instead of ground meat. A nurse’s note recorded that the resident received a whole chicken strip for lunch and choked on a bite of chicken. Staff statements confirmed that dietary staff provided a whole chicken strip, and one dietary staff member stated he had chopped one up but then set it aside and gave her a whole chicken strip because he could not remember if they were supposed to be chopped for her. This action directly conflicted with the resident’s ordered mechanical soft diet with ground meat and the facility’s own policies requiring foods to be cut, chopped, or ground to meet individual needs and specifying that meat, fish, and poultry on mechanical soft diets should be chopped, flaked, or ground. When the resident began choking, another resident alerted staff in the dining room. Staff observed the resident choking, and a CNA and another staff member attempted and then performed the Heimlich maneuver, resulting in the resident expelling a chunk of food onto the floor and stating she felt better. A prior progress note also documented that the resident had experienced a possible choking episode in the dining room on an earlier date, during which she was observed coughing with blue lips, encouraged to cough up a moderate amount of mushy substance, and suctioned for a moderate amount of thick, clear mucus. The facility’s dietary and nursing staff interviews described an established process using diet cards and multiple verification steps to ensure correct diet texture and consistency, but staff acknowledged that this process was not thoroughly followed for this resident’s meal, resulting in her receiving a full chicken strip instead of the ordered mechanical soft, ground meat diet. This failure led to a choking episode that surveyors determined constituted Immediate Jeopardy.
Removal Plan
- Provide in-service education for dietary monitoring and ensuring proper diets are served to each resident for direct-care staff and kitchen staff
- Provide 1:1 education with the cook and dietary aide
- Implement disciplinary action for the cook and dietary aide
- Provide 1:1 in-service education with all staff who serve in the dining room
- Revise the dining room monitoring schedule to include manager coverage for all meals
- Verify all at-risk residents to ensure diets match their diet cards
- Provide RELIAS educational training for the cook
- Hold a QAPI meeting with the Director of Nursing, Administrator, and Medical Director
Failure to Supervise Elopement-Risk Resident and Identify Prolonged Elopement
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and maintain an environment free from accident hazards, resulting in an elopement. A resident with a diagnosis of schizoaffective disorder, hallucinations, delusions, rejection of care, and wandering behaviors was assessed as having intact cognition with a BIMS score of 15 and was care planned as being at moderate to high risk for elopement. The resident’s care plan included interventions such as increased supervision during exit-seeking behaviors, placement in a room away from exits, lodging in a secure unit, medication review, psychiatric services as needed, and use of a WanderGuard with placement and function checks. The WanderGuard was intended to limit the resident’s ability to enter the backyard without staff present. Despite these identified risks and planned interventions, the resident was able to access the smoking patio and leave the facility without staff knowledge or supervision. At approximately 2:45 AM, the resident used a dining room chair placed on the smoking patio to climb over the tall fence surrounding the patio and exit the premises. The door to the patio remained unlocked, and although the WanderGuard alarmed at the door and indicated the need for staff assistance, the resident still gained access to the patio and then climbed the fence. The facility’s cameras later showed the resident using the chair to scale the fence. Staff statements indicated that the last known observations of the resident occurred between approximately 9:00 PM and 2:00 AM, with no indications of unrest reported at those times. After leaving the facility, the resident walked approximately 1.8 miles to a truck stop, remained there for several hours, and then walked back to the facility, returning around 11:45 AM. During this time, outdoor temperatures ranged from 29.9°F to 45.3°F. Staff were unaware of the resident’s absence for about nine hours due to a failure to complete resident safety rounds on both the night and day shifts. Multiple staff members, including CNAs, a CMA, and an LN, reported not completing rounds or not entering the resident’s room, with one nurse noting that the resident’s curtain was pulled and she did not verify his presence. The resident ultimately rang the front doorbell to re-enter the facility, at which point staff assessed him and confirmed he had no injuries. The surveyors determined that the failure to complete rounds and adequately supervise the resident, combined with the environmental setup that allowed use of a movable chair to climb the fence, resulted in an elopement that constituted immediate jeopardy.
Removal Plan
- Update R1's care plan.
- Place a WanderGuard on R1.
- Conduct education on elopement and rounds with staff.
- Give written warnings to staff for failure to complete rounds.
- Complete magnetic lock checks on the doors.
- Complete an Ad-Hoc Quality Assurance and Performance Improvement (QAPI) meeting.
- Complete an elopement drill.
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