Aberdeen Village
Inspection history, citations, penalties and survey trends for this long-term care facility in Olathe, Kansas.
- Location
- 17500 W 119th Street, Olathe, Kansas 66061
- CMS Provider Number
- 175448
- Inspections on file
- 17
- Latest survey
- February 10, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Aberdeen Village during CMS and state inspections, most recent first.
A resident with Alzheimer’s disease, prior stroke, insomnia, and major depressive disorder was maintained on Quetiapine for “unspecified dementia with psychotic disturbances” without a CMS-approved indication and without behavioral monitoring. The MDS showed severe cognitive impairment but no documented behaviors, and the care plan referenced resisting care and yelling out but did not include a clear psychiatric indication for antipsychotic use. The resident was observed calm and behavior-free, while the EMR lacked behavior tracking tied to the antipsychotic. A consultant pharmacist recommended gradual dose reduction, which the provider declined, and staff acknowledged that antipsychotics are not indicated for dementia alone and that the resident’s representative refused medication changes, leaving the facility unable to document an appropriate rationale consistent with its own psychotropic medication policy.
Surveyors found that a resident was maintained on Quetiapine for an indication of unspecified dementia with psychotic disturbances without a clearly documented CMS-approved psychiatric indication. The MDS showed no documented behaviors during the assessment period, and the care plan referenced behaviors and use of Quetiapine but did not specify a psychiatric indication or include behavioral monitoring. The consultant pharmacist’s monthly reviews recommended gradual dose reduction, which the provider declined, but did not address the inappropriate dementia-related indication, and the facility could not produce documentation supporting an appropriate indication despite acknowledging that antipsychotics are not indicated for dementia alone.
A resident with Alzheimer's and moderate cognitive impairment eloped from a facility due to inadequate supervision and unsecured exits. The resident, who required assistance for ambulation and was at risk for falls, left the facility unnoticed and was found by law enforcement at a nearby gas station. The facility's elopement risk assessment did not identify the resident as at risk, and the care plan did not address elopement potential.
The facility failed to follow sanitary dietary standards, including improper food storage, lack of temperature log checks, and inadequate hand hygiene by dietary staff, placing residents at risk of foodborne illnesses.
The facility failed to store medications and biologicals appropriately when the medication room was found unlocked and a resident's insulin pens were not labeled with the open date. Staff were expected to ensure the medication room was locked at all times and insulin pens were labeled and stored properly.
The facility failed to ensure adequate infection control standards, including the use of enhanced barrier precautions, PPE, and proper indwelling catheter maintenance. Inspections revealed missing signage and PPE in residents' rooms and improper handling of a urinary catheter bag. Staff acknowledged awareness of the requirements but did not consistently implement them, placing residents at risk for infections.
The facility failed to honor a resident's request to move to the TV room during breakfast and did not maintain another resident's dignity during transfers in a common area, leading to exposure. Staff ignored the first resident's repeated requests and did not assist him, while the second resident was exposed during transfers due to improper handling by the staff.
The facility failed to ensure a resident received necessary assistive services for transfers, leading to the use of a gait belt that exposed the resident's skin and did not provide adequate support. Staff were inconsistent in following the care plan, which indicated the use of a pivot disc and walker.
The facility failed to ensure a resident's low air-loss mattress pump was set correctly according to their weight, and did not complete weekly wound assessments for another resident with a pressure ulcer. These deficiencies placed the residents at risk for complications related to skin breakdown and pressure ulcers.
A facility failed to provide appropriate treatment for a resident with an indwelling catheter by allowing the catheter drainage bag to rest on the floor. The resident had a history of frequent UTIs and required assistance for proper hygiene. Observations and staff interviews confirmed the improper placement of the catheter bag, which should have been stored in a dignity bag attached to the bed.
A resident's CPAP mask was repeatedly observed to be laid directly on the bedside table without containment, contrary to facility policy. Staff interviews confirmed the improper storage practice, which increased the resident's risk for respiratory infection and complications.
The facility failed to identify a resident's low air-loss mattress and bolstered overlay as potential risks in the side rail assessment, placing the resident at risk for inadequate care due to unidentified care needs. Staff were unsure if the assessments differentiated between mattress types and overlays, contrary to facility policy.
Inappropriate Antipsychotic Use Without CMS-Approved Indication
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to ensure a resident remained free from chemical restraint through the inappropriate use of an antipsychotic medication without a CMS-approved indication. The resident had diagnoses including Alzheimer’s disease, cerebral infarction, insomnia, and major depressive disorder, with a BIMS score indicating severe cognitive impairment but no documented behaviors on the MDS during the assessment period. The care plan, initiated months earlier, described behaviors of resisting care and yelling out related to depression, anxiety, and dementia, and noted the use of Quetiapine (Seroquel) for these behaviors, but it did not include a psychiatric indication for the antipsychotic. The physician’s order renewed Quetiapine 12.5 mg daily for “unspecified dementia with psychotic disturbances,” and the resident had been admitted on this medication and diagnosis. Record review showed no behavioral monitoring related to the antipsychotic use, despite the resident’s psychotropic CAA identifying antipsychotic use and risk for adverse effects. Consultant pharmacist documentation over several months included a recommendation for gradual dose reduction of Quetiapine, which the provider declined, citing risk of decompensation, but the recommendations did not address the lack of an appropriate CMS indication for use in dementia. The facility was unable to provide a documented rationale for continued Quetiapine use without an appropriate CMS indication when requested. Observations showed the resident calm, engaged in group activity, and without behaviors at the time of surveyor observation. Interviews with facility staff confirmed that antipsychotics are not indicated for dementia alone and that dementia was the listed indication, with staff acknowledging that the resident’s representative refused changes to the medication or its indication. The facility’s own policy required psychotropic drugs to be used with specific diagnoses and to be closely monitored, but this was not supported by the documentation for this resident’s antipsychotic therapy.
Failure to Ensure Appropriate CMS-Approved Indication for Antipsychotic Therapy
Penalty
Summary
Surveyors identified a deficiency in the facility’s drug regimen review process related to the use of an antipsychotic medication for a resident with dementia. The resident’s EMR listed diagnoses of Alzheimer’s disease, cerebral infarction, insomnia, and major depressive disorder, with a BIMS score indicating severe cognitive impairment. The MDS showed the resident was independent in activities of daily living and did not exhibit behaviors during the assessment period, though it documented antipsychotic use. The CAA noted antipsychotic use and risk for adverse effects from Seroquel. The care plan, initiated earlier, described behaviors of resisting care and yelling out related to depression, anxiety, and dementia, and stated that Quetiapine (Seroquel) was used for these behaviors, but it lacked a clear psychiatric indication for the medication. The EMR contained a renewed order for Quetiapine 12.5 mg daily with an indication of unspecified dementia with psychotic disturbances, and there was no behavioral monitoring documented related to the antipsychotic use. Review of the consultant pharmacist’s monthly recommendations from May through February showed that the pharmacist recommended a gradual dose reduction of Quetiapine to the lowest effective dose, which the medical provider declined, citing risk of decompensation. The pharmacist’s recommendations did not address the use of the antipsychotic with the indication of dementia, and the facility could not provide documentation supporting a CMS-approved indication for the continued use of Quetiapine despite a request for such rationale. Observations showed the resident calm and engaged in group activity without behaviors. Interviews revealed that the consultant pharmacist stated the resident was admitted on the antipsychotic and that the representative refused changes or discontinuation, and that the medication was believed to be needed for dementia-related hallucinations and delusions. A nurse and an administrative nurse both stated that antipsychotics were not indicated for dementia alone and required a psychiatric diagnosis, and that the resident had been admitted with the medication and dementia diagnosis. This sequence of actions and inactions demonstrated a failure to ensure the consultant pharmacist addressed the lack of an appropriate CMS indication for the antipsychotic during the monthly drug regimen review, contrary to the facility’s drug regimen review policy.
Inadequate Supervision Leads to Resident Elopement
Penalty
Summary
The facility failed to provide adequate supervision to prevent the elopement of a cognitively impaired resident, who required staff assistance for activities of daily living, including safe ambulation with a walker, and was at risk for falls. On the early morning of 10/17/24, a Certified Nurse Aide (CNA) heard the resident's toilet flush and checked on her. The resident indicated she did not need assistance, and the CNA left to assist another resident, assuming the resident would return to bed. However, the resident subsequently left her room, took the elevator to the first floor, and exited the facility without staff knowledge or supervision. The resident, who had a diagnosis of Alzheimer's disease, unspecified dementia, osteoporosis, syncope, and a history of falls, was found by law enforcement at a nearby gas station and returned to the facility. The resident's electronic medical record indicated moderate cognitive impairment and a need for supervision during ambulation. Despite these needs, the resident's care plan did not address elopement potential prior to the incident. The facility's elopement risk screen conducted before the incident indicated the resident was not at risk for elopement, and there were no previous elopement attempts recorded. The facility's investigation revealed that the resident was able to exit the facility through a series of doors that did not have adequate security measures to prevent such an occurrence. The main entrance doors were accessible without a keypad lock, and there was no staff present in the main lobby area after 01:00 AM to monitor the resident's movements. The facility's failure to provide adequate supervision and secure the facility's exits allowed the resident to leave the premises unnoticed, placing her in immediate jeopardy.
Removal Plan
- A WanderGuard was placed on R1 with orders to monitor and document function each shift.
- R1's care plan was updated to include an intervention and monitoring for R1's WanderGuard.
- Staff completed an updated Elopement screening on R1 to reflect R1's new risk and behavior.
- The facility contacted maintenance and the facility door contractor to inspect the unit door's locking systems to ensure there was no other point of failure.
- The facility ordered parts to have a set of double doors coded with a keypad lock to prevent future elopements through those doors.
- Administrative Nurse D was in the process of providing education for all staff related to elopement, wandering, and missing residents.
Failure to Follow Sanitary Dietary Standards
Penalty
Summary
The facility failed to follow sanitary dietary standards related to cleaning, food storage, equipment storage, and food preparation practices. During an initial tour, it was observed that bowls were stored upright instead of inverted, and temperature logs for refrigerators, freezers, and the dishwasher lacked evidence of being checked on specific dates. Additionally, the walk-in freezer had uncovered and undated breaded chicken breasts, and open containers of cottage cheese and milk were not dated. A commercial meat slicer was found uncovered but not in use. These observations indicate a lack of adherence to proper food storage and equipment maintenance protocols, which are essential for preventing foodborne illnesses and ensuring food safety for residents. Further observations revealed that a dietary staff member did not perform hand hygiene before beginning food preparation and handled food and utensils with contaminated gloves. The staff member touched unclean surfaces and then directly handled food without changing gloves or performing hand hygiene. This practice continued as the staff member doffed gloves and proceeded to clean surfaces without washing hands, and later used an ungloved hand to grab a spatula by the end that touches food. Interviews with dietary staff confirmed that these actions were against the facility's policies, which require hand hygiene and proper use of gloves to prevent cross-contamination and foodborne illnesses. The facility's policies on hand hygiene and food storage were not followed, placing residents at risk of food safety concerns.
Failure to Secure Medication Room and Label Insulin Pens
Penalty
Summary
The facility failed to store medications and biologicals appropriately when the medication room on the second floor was found unlocked during an inspection. The room contained a secured digital medication storage system, a locked medication refrigerator, and a shelf with unsecured over-the-counter medications. Licensed Nurse J secured the room upon completion of the inspection. Additionally, an inspection of a medication cart revealed that a resident's insulin pens were not labeled with the open date, which is required to ensure proper usage and disposal within 28 days. Licensed Nurse G immediately removed the unlabeled insulin pens from the cart. Licensed Nurse J stated that staff were expected to ensure the medication room door was fully shut and locked at all times to prevent resident access to medications and nursing equipment. Administrative Nurse D confirmed that the medication rooms were expected to be locked at all times and that insulin pens should be labeled with the open date and stored in the medication carts. The facility's Medication Storage policy indicated that all medications and biologicals should be stored safely following the manufacturer's storage recommendations and properly labeled with the recommended expiration dates.
Inadequate Infection Control Standards
Penalty
Summary
The facility failed to ensure adequate infection control standards related to enhanced barrier precautions, wearing personal protective equipment (PPE), and indwelling catheter maintenance. During inspections, it was observed that several residents' rooms lacked the necessary signage and PPE for enhanced barrier precautions. Specifically, rooms of residents with wound care and indwelling urinary catheters did not have the required signage or PPE posted. Additionally, a certified nurse aide entered a resident's room with a bacterial urinary infection and performed peri-care without donning the required PPE, despite the presence of a contact isolation sign and PPE outside the room. Further observations revealed that a resident's urinary catheter bag was improperly placed on the floor, which is against the facility's infection control policy. Interviews with staff confirmed that they were aware of the requirements for enhanced barrier precautions and PPE usage, as they had recently undergone training on these topics. However, the staff failed to consistently implement these precautions, placing residents at risk for infectious diseases. The facility's policies on infection control and catheter care were not adequately followed, leading to these deficiencies.
Failure to Honor Resident Requests and Maintain Dignity
Penalty
Summary
The facility failed to honor a resident's request during dining and maintain another resident's dignity during care in a common area. One resident repeatedly asked to be moved to the TV room during breakfast, but staff ignored his requests and did not assist him, even though his wheelchair was locked and he could not move himself. The resident expressed frustration and was visibly distressed, coughing and spitting out food without receiving timely assistance from the staff. Eventually, a social services staff member moved him to the TV room after he had been ignored for an extended period. Another resident, who had severe cognitive impairment and required substantial assistance with transfers, was exposed during transfers in the common area. The licensed nurse used a gait belt to lift the resident, causing her shirt to rise and expose her skin from the waist to the breast area. This occurred on multiple occasions, and the staff acknowledged that the resident should not have been exposed in a common area. The facility's policy on resident rights and dignity was not followed, leading to the resident's exposure and potential negative psychosocial outcomes. The facility's policy emphasized the importance of treating residents with respect and dignity, ensuring their rights to a dignified existence and self-determination. However, the staff's actions and inactions in these instances did not align with the policy, resulting in deficiencies that compromised the residents' dignity and self-worth.
Failure to Provide Necessary Assistive Services for Transfers
Penalty
Summary
The facility failed to ensure that Resident 46 received the necessary assistive services for transfers, which placed the resident at risk for loss of independence, decreased self-esteem, and impaired dignity. Resident 46 had a history of cerebral infarction, dementia, and depression, and was documented to have severely impaired cognition. The resident's care plan indicated the use of a pivot disc and walker for transfers. However, observations on multiple occasions showed that staff did not use these assistive devices during transfers, instead using a gait belt that exposed the resident's skin and did not provide adequate support for weight-bearing. Interviews with staff revealed inconsistencies in their knowledge and application of the resident's care plan. Certified Nurse Aide M and Licensed Nurse G both indicated that the resident was transferred with a gait belt and one staff person, but were unsure about the use of a pivot disc and walker. Administrative Nurse D confirmed that staff should follow the care guide, which is based on the care plan, and that any changes in a resident's status should be reported for re-evaluation. The facility's policy on Resident Rights and Responsibilities emphasized the importance of treating residents with dignity and providing person-centered care, which was not upheld in this case.
Failure to Implement Pressure-Reducing Interventions and Complete Weekly Wound Assessments
Penalty
Summary
The facility failed to ensure that a resident's pressure-reducing interventions were implemented correctly. Specifically, the low air-loss mattress pump for a resident with severe cognitive impairment and a Stage 3 pressure ulcer was set at an inaccurate weight of 280 lbs, despite the resident weighing only 107 lbs. This discrepancy was observed over multiple days, and staff interviews confirmed that the mattress should have been set to 120 lbs according to the resident's current weight. The facility's policy required staff to check the bed function and settings each shift, but this was not adhered to, placing the resident at risk for complications related to skin breakdown and pressure ulcers. The facility also failed to complete weekly wound assessments for another resident with a history of cerebral infarction, early onset Alzheimer's disease, and hemiplegia. This resident had a Stage 2 pressure ulcer and was at moderate risk for pressure ulcer development. The resident's electronic medical record lacked evidence of weekly wound assessments over several weeks, with gaps of 14 and 34 days between documented assessments. Staff interviews revealed that the unit charge nurse and wound care nurse were responsible for weekly skin checks and wound assessments, but these were not consistently performed or documented. The facility's policies on skin integrity and pressure ulcer prevention required weekly skin evaluations by a licensed nurse and the implementation of wound treatment orders when pressure ulcers were present. However, these policies were not followed, resulting in missed assessments and inadequate monitoring of the resident's pressure injuries. This failure placed the resident at risk for further complications related to skin breakdown and pressure ulcers.
Failure to Properly Manage Catheter Care
Penalty
Summary
The facility failed to provide appropriate treatment for a resident with an indwelling catheter by allowing the catheter drainage bag to rest on the floor. The resident, who had diagnoses of bladder cancer, dementia, and urinary retention, had a history of frequent urinary tract infections (UTIs) and required assistance from staff for proper hygiene related to the care of his indwelling catheter. Observations revealed that the catheter bag contained dark amber urine and was placed directly on the floor at the foot of the resident's bed. Interviews with staff confirmed that the catheter drainage bag should never be placed on the floor and should be stored in a dignity bag attached to the bed to prevent infections. The resident's medical records documented multiple physician orders for antibiotics to treat recurrent UTIs, indicating a history of infection complications. Despite the facility's policy on catheter care, which mandates that catheter care be performed appropriately by qualified nursing staff to prevent complications, the facility failed to adhere to this policy. This deficiency placed the resident at risk for further catheter-related complications and UTIs, as evidenced by the improper placement of the catheter drainage bag on the floor.
Improper Storage of CPAP Mask
Penalty
Summary
The facility failed to ensure the proper storage of a resident's CPAP mask, which was observed to be laid directly on the bedside table without containment on multiple occasions. The resident, who had a history of obstructive sleep apnea and other medical conditions, was dependent on staff for all activities of daily living and had moderately impaired cognition. Despite physician orders to apply the CPAP at bedtime and remove it in the morning, the staff consistently placed the mask on the bedside table without using a sanitary storage method. Interviews with staff revealed a lack of adherence to the facility's policy on CPAP mask storage. A Certified Nurse's Aide stated that the mask was always placed on the bedside table, while a Licensed Nurse and an Administrative Nurse confirmed that the mask should be stored in a dated plastic bag. The facility's Oxygen Therapy policy also required that the device be stored in a plastic or other bag when not in use. The failure to follow these guidelines placed the resident at an increased risk for respiratory infection and complications.
Failure to Identify Risks Associated with Bed Rail Assessment
Penalty
Summary
The facility failed to identify a resident's low air-loss mattress and bolstered overlay as potential risks in the side rail assessment. The resident, who had severe cognitive impairment, Alzheimer's disease, major depressive disorder, a stage 3 pressure ulcer, and a history of falls, was using a low air-loss mattress and bolstered overlay provided by hospice services. Despite these devices being in place, the facility's assessment did not account for the specific risks associated with the mattress and overlay, which could lead to gaps between the rail and bed, possible strangulation hazards, and the effectiveness of the assist rails. Observations and interviews revealed that the facility's staff, including the licensed nurse and administrative nurse, were unsure if the risk assessments differentiated between mattress types and overlays. The facility's policy required continual assessment of assistive devices attached to beds to ensure safety, but the assessment for this resident did not identify the low air-loss mattress or bolstered overlay as risks. This oversight placed the resident at risk for inadequate care due to unidentified care needs.
Latest citations in Kansas
Surveyors identified unsanitary food storage and preparation conditions, including food debris in a reach-in freezer, an unknown spilled liquid in a reach-in refrigerator, missing two-inch air gap on an ice machine drain, dirty carts used for clean dishes, and a steamtable shelf with built-up food debris. A dietary staff member acknowledged these areas needed cleaning, and it was determined the facility lacked a cleaning schedule or policy for kitchen cleanliness.
The facility failed to complete and analyze Care Area Assessments (CAAs) for multiple residents after Admission, Annual, and Significant Change MDS assessments triggered areas such as cognition, mood/behavior, functional status, urinary incontinence/indwelling catheter, nutrition, dental care, pressure ulcers, pain, falls, psychotropic drug use, psychosocial well-being, and visual function. Instead of documenting individualized analysis of underlying causes and contributing factors, an LPN reported she had stopped writing CAA notes and relied mainly on check-off worksheets and the fact that triggers appeared in the MDS CAA section. No facility policy on CAAs was provided to surveyors, and the CAAs consistently lacked required analytical documentation for residents with diverse and significant clinical needs.
A resident with dementia, severe cognitive impairment, and an indwelling urinary catheter was repeatedly observed sitting in common areas with his catheter drainage bag resting on his lower leg, visibly filled with dark amber urine and lacking a privacy cover, despite a care plan directing staff to cover the drainage bag. CNAs reported that the bag often slid down from the resident’s thigh, that they did not use catheter dignity bags on their hall, and that they simply moved the bag back up when it slid down. An administrative nurse stated she had not considered the use of dignity bags on the memory care unit, even though the facility’s resident rights policy affirms each resident’s right to a dignified existence, privacy, and confidentiality.
Two residents with documented cognitive ability to participate in care planning were not invited to any care plan meetings, and their EMRs lacked evidence of care plan conferences, invitations, or Interdisciplinary Care Conference assessments. Administrative staff stated that invitations should be mailed or hand-delivered and uploaded to the EMR, and that an Interdisciplinary Care Conference note should be completed, but none of this documentation existed for these residents, contrary to facility policy and federal requirements for resident and/or representative participation in care planning.
A resident with C-diff and CHF, newly admitted and with a baseline care plan that did not address call light use, was repeatedly found without access to a call light. Surveyors observed the resident yelling for help with her room door closed and later noted the call light on the floor under the bed and again on the floor while the resident sat in a recliner and stated she wanted to return to bed but could not do so independently. Staff reported using a binder clip to attach the call light to the resident’s clothing because the cord lacked a clip, acknowledged the resident sometimes threw the call light to the floor, and stated that call lights should be kept within residents’ reach. An administrative nurse confirmed the expectation that call lights be accessible at all times and was unsure about the use of a binder clip, and no facility policy on call lights was provided.
Surveyors found that a resident’s bathroom and handwashing area were not maintained in a safe, sanitary, and comfortable condition, including a loose baseboard with black substance behind it, a cracked toilet seat, and an empty, improperly mounted hand soap dispenser. Maintenance staff confirmed these conditions, noted that the soap dispenser was nonfunctional, and reported that although a QR code system existed for reporting maintenance issues, these problems had not been reported. Maintenance staff also stated there were no facility policies for maintenance repair in resident rooms and no policy provided for ensuring a safe, homelike environment.
Multiple residents were affected by inaccurate MDS assessments, including a resident with dementia and an indwelling catheter who was miscoded as always incontinent of urine and independent in ADLs despite staff and EMR documentation showing long-term catheter use and total dependence for dressing and wheelchair positioning. Another resident with a history of stroke was incorrectly coded as having a restraint, even though bed grab bars were used as enablers to assist with repositioning and did not limit voluntary movement. A resident with diabetes and unsteadiness experienced two documented falls that were not captured on the MDS, and another resident with diabetes, depression, CAD, and CKD was actively receiving hospice services per EMR, social services, and staff interviews, yet hospice was not coded on the MDS. The consultant MDS nurse confirmed these were significant coding errors not in accordance with the RAI User’s Manual.
A resident with C. diff and CHF was admitted, and while a baseline care plan documenting contact precautions was created, the resident later reported not knowing what a baseline care plan was. The resident was also found yelling for help with her call light on the floor under the bed. Nursing staff stated that baseline care plans are started on the day of admission and reviewed with residents, but also indicated that residents and families are not given written copies. An administrative nurse claimed a 48-hour interdisciplinary care conference had been completed, yet no corresponding documentation existed in the EMR, and explanations about who was responsible and why it was missing were inconsistent. No facility policy for baseline care plans was provided.
A resident with dementia and severe cognitive impairment was inaccurately assessed and care planned as needing only setup or independent assistance with dressing, despite actually requiring total staff assistance. The EMR lacked clear ADL documentation, and the ADL CAA did not trigger, leading to inaccurate MDS entries and a care plan that did not match the resident’s functional status. Surveyors observed the resident sitting in a wheelchair wearing dirty, food-stained pants and being taken to the dining room without a clothing change, with the soiled pants not changed until later when two CNAs provided total assistance. Staff, including CNAs, an LN, and an administrative nurse, acknowledged that the resident needed total help with dressing and should always be in clean clothing, revealing a failure to provide appropriate ADL support and maintain clean attire.
A resident with dementia and severe cognitive impairment was transported multiple times in a wheelchair without staff ensuring that his feet remained safely on the foot pedals. Although assessments inaccurately documented that he was independent with walking using a walker and/or wheelchair, his care plan did not instruct staff on proper use of wheelchair foot pedals. During observed transports by CNAs, the resident’s shoed feet repeatedly fell off the pedals and skimmed the floor between them. Staff acknowledged that his feet did not stay on the pedals and that the pedals were not effectively adjusted, and nursing leadership confirmed expectations that feet should remain on the pedals during transport. No wheelchair safety policy was provided.
Unsanitary Kitchen Conditions and Lack of Cleaning Policy
Penalty
Summary
The facility failed to prepare and serve food under sanitary conditions when surveyors observed multiple cleanliness and equipment issues in the kitchen. During an initial kitchen tour on 04/27/26 at 08:57 AM, the three-door reach-in freezer was found with food debris on the bottom shelf, and the three-door reach-in refrigerator had an unknown spilled liquid on the bottom shelf. The drain to the ice machine did not have the required two-inch air gap. Two black two-tiered plastic carts used to store clean dishes had food debris on the bottom tier, and the bottom shelf of the steamtable, which was used to store plate covers, had a buildup of food debris. On 04/28/26 at 01:57 PM, a dietary staff member confirmed these areas required cleaning, and it was identified that the facility did not have a cleaning schedule or a policy regarding kitchen cleanliness. No specific residents, medical histories, or clinical conditions were mentioned in the report in relation to this deficiency.
Failure to Complete and Analyze Care Area Assessments for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to complete comprehensive Care Area Assessments (CAAs) with analysis of underlying causes, contributing factors, and risk factors for multiple residents following MDS assessments. Record review showed that numerous residents had Admission, Annual, or Significant Change MDS assessments that triggered CAAs in areas such as mood/behavior, cognitive loss/dementia, functional abilities, communication, urinary incontinence/indwelling catheter, nutritional status, dental care, pressure ulcers, pain, falls, psychotropic drug use, psychosocial well-being, visual function, and psychosocial well-being. For each of these triggered areas, the corresponding CAAs lacked analysis of the findings. This pattern was identified for residents with a wide range of clinical issues, including dementia, incontinence, falls, pressure ulcers, nutritional concerns, psychotropic medication use, pain, and functional decline. During an interview, a licensed nurse reported that she had stopped writing CAA notes the previous year after being told to do so by someone she could not identify. She stated that she did not write anything on the triggered CAAs and that, at times, she would document risk concerns only on a main check-off worksheet, relying on the fact that the triggers were already reflected in the MDS CAA section. The facility did not provide a policy regarding CAAs when requested. These findings demonstrate that the facility did not ensure that comprehensive assessments were fully completed as required when residents were first admitted and periodically thereafter.
Failure to Maintain Dignity and Privacy for Resident with Indwelling Catheter
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s right to a dignified existence by not maintaining privacy for his urinary catheter drainage bag as directed in his care plan. The resident had diagnoses including bladder calculus and dementia, with a BIMS score of one indicating severe cognitive impairment, and was dependent on staff for toileting hygiene with an indwelling urinary catheter and constant urinary incontinence. His care plan, revised 03/23/26, instructed staff to cover his drainage bag with a privacy cover. However, during observations on 04/27/26, the resident was seen sitting in his wheelchair at his room doorway and later in the dining room with his catheter drainage bag resting on his lower left leg, supported by his shoe, containing dark amber urine and visible to visitors and other residents, without a privacy cover. Staff interviews confirmed that the catheter drainage bag frequently slid from the resident’s left thigh down to his lower leg and that staff did not consistently reposition it or use dignity/privacy bags. One CNA stated he had never placed a dignity bag on the resident’s drainage bag, and another CNA reported that staff on their hall did not utilize catheter dignity bags, instead just moving the bag back up when it slid down. An administrative nurse acknowledged she had not considered staff use of dignity bags for urinary catheters on the memory care unit. The facility’s Resident Rights policy, approved 12/2024, stated that each resident has the right to a dignified existence including privacy and confidentiality, which was not followed in this case.
Failure to Involve Cognitively Able Residents in Care Plan Meetings
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were given the opportunity to participate in the development and implementation of their person-centered plans of care. For one resident with a Brief Interview of Mental Status (BIMS) score of 12, indicating moderately impaired cognition, the electronic medical record showed an admission MDS and a Significant Change MDS, but there was no documentation of any care plan meeting in the prior four months. This resident reported not being invited to any care plan meeting. For a second resident with a BIMS score of 14, indicating intact cognition, the electronic medical record contained an admission MDS and a Quarterly MDS, but there was no documentation of a care plan meeting in the prior two months. This resident also reported not being invited to any care plan meeting. Administrative staff reported that residents and/or family members were supposed to be mailed or hand-delivered invitations to attend care planning meetings and that a copy of the invitation should be uploaded into the EMR. They further stated that an Interdisciplinary Care Conference assessment should be completed in the EMR during the care plan meeting. However, the administrative nurse confirmed that there was no documentation of invitations, Interdisciplinary Care Conference assessments, or completed care plan meetings for the two residents. The facility’s care planning policy stated that social services should attend care plan meetings and that the team presents information to the resident and/or representative about progress toward care plan goals, and referenced federal law requiring resident and/or representative participation in care plan meetings to the extent possible, but this process was not carried out or documented for the two residents identified.
Failure to Keep Call Light Within Reach for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s call light was within reach and to reasonably accommodate the resident’s needs and preferences. The resident had documented diagnoses of C-diff and CHF, and her baseline care plan dated 04/23/26 directed staff to evaluate for changes in level of consciousness but did not include any direction regarding call light use or accessibility. On 04/28/26 at 08:06 AM, surveyors observed the resident’s room door closed while she yelled loudly for help several times. When a licensed nurse entered the room, the resident was lying on her left side in bed, stated she wanted to get up, and reported she could not find her call light. The call light was observed on the floor under her bed. Later that morning, a CNA attached the call light to the resident’s shirt using a black and silver binder clip because the call light cord did not have its own clip. On 04/29/26 at 12:15 PM, the resident was seated in a recliner with the call light again lying on the floor out of her reach; she reported she wanted to go to bed and could not get herself back into bed. Staff interviews revealed that the CNA used the binder clip to keep the call light attached to the resident, and the licensed nurse stated staff should make sure the call light is clipped to the resident’s clothes and reported that the resident would throw her call light on the floor. An administrative nurse stated she expected staff to ensure all residents always have their call lights in reach and was unsure about using a binder clip to hold a call light in place. The facility did not provide a policy regarding call lights.
Failure to Maintain Safe and Sanitary Resident Bathroom Environment
Penalty
Summary
Surveyors identified that the facility failed to maintain a safe, functional, sanitary, and comfortable environment in Resident 87’s bathroom and handwashing area. During an environmental tour with Maintenance Staff UU, surveyors observed an approximately four-foot section of loose baseboard to the left of and behind the toilet, with a black substance present on the wall and floor behind the loose baseboard. They also noted an approximately three-inch crack in the toilet seat and an empty hand soap dispenser hanging above the handwashing sink, mounted with exposed lag bolt fasteners. Maintenance Staff UU confirmed these conditions, acknowledged that the soap dispenser did not work, and stated that the toilet seat should be replaced, the bathroom baseboard removed, the black substance tested for mold, and the sheetrock removed and replaced. Further interview with Maintenance Staff UU revealed that the facility had implemented a QR code system for staff and visitors to report maintenance items, but the issues in this resident’s bathroom had not been reported through that system. He also reported that there had been a leak behind the handwashing sink that had flowed into the bathroom area, leading to the sink’s replacement, but he had received no report of the specific deficiencies observed in the bathroom. Additionally, Maintenance Staff UU stated that the facility did not have policies for maintenance repair in residents’ rooms, and the facility did not provide a policy for ensuring a safe, homelike environment.
Inaccurate MDS Coding for ADLs, Restraints, Falls, and Hospice Services
Penalty
Summary
The deficiency involves the facility’s failure to complete accurate Minimum Data Set (MDS) assessments in accordance with the Resident Assessment Instrument (RAI) User’s Manual, resulting in multiple residents’ clinical status not being correctly reflected. For one resident with dementia and severe cognitive impairment, the Significant Change and subsequent Quarterly MDS assessments coded him as always incontinent of bladder and independent with eating and upper body dressing, with use of a walker and wheelchair. However, the electronic medical record showed ongoing indwelling catheter care each shift and no documentation of walker use, wheelchair mobility, or dressing requirements during the review period. Staff interviews revealed that this resident had an indwelling catheter for more than a year, had not walked for several years, and was dependent on staff for all ADLs, including dressing and wheelchair positioning, contradicting the MDS coding. Observations showed the resident slumped in a wheelchair, wearing a hospital gown over clothing, with a visible catheter bag on his lower leg and feet frequently skimming the floor despite foot pedals being present, further indicating dependence and catheter use not accurately captured on the MDS. Another deficiency involved a resident with a history of stroke, hemiplegia, and hemiparesis whose Significant Change MDS coded the use of “other restraint.” During observation, the resident was seen in bed with bilateral grab bars at the head of the bed and her right arm positioned on a pillow. The resident reported using the grab bars to help move and reposition herself in bed. CNAs and administrative nursing staff confirmed that the facility did not use restraints and that the grab bars were used as enablers to assist residents with repositioning and to increase independence. Administrative staff acknowledged that the MDS coding for restraints was inaccurate because the grab bars did not limit the resident’s voluntary movement or access to her body. A further inaccuracy was identified for a resident with diabetes, atrial fibrillation, unsteadiness of feet, and a toe fracture. Both a Significant Change and a Quarterly MDS documented intact cognition, partial/moderate assistance with transfers, no ambulation, and no falls. However, progress notes in the EMR documented two unwitnessed falls during the look-back period, including one where the resident was found on the floor next to the bed with a forehead skin tear and another where the resident was found sitting on a fall mat on the floor with a scratch on the ankle. These documented falls were not reflected on the MDS. In addition, another resident with diabetes, depression, CAD, and chronic kidney disease had a Significant Change MDS that coded no hospice services, while the EMR contained a hospice certification and physician orders initiating hospice services, and social service notes and staff interviews confirmed that hospice services, including bathing by a hospice aide, were being provided during the look-back period. The consultant MDS nurse confirmed that these assessments were inaccurate and not completed in accordance with the RAI User’s Manual, constituting significant errors in coding for urinary status, ADL dependence, restraints, falls, and hospice services. The consultant MDS nurse stated that the resident with the indwelling catheter should have been coded as not rated for urinary continence due to catheter placement rather than as always incontinent, and that his ADL status should not have been coded as independent given his dependence on staff for dressing and wheelchair positioning. For the resident with grab bars, the nurse confirmed that the grab bars were used as enablers and not as restraints, making the restraint coding inaccurate. For the resident with documented falls, the MDS failed to capture falls that occurred within the look-back period, and for the resident receiving hospice services, the MDS did not reflect hospice care that was active during the look-back period. These miscodings met the RAI Manual’s definition of significant error, in which the resident’s overall clinical status is not accurately represented on the assessment and the error has not been corrected by a more recent assessment.
Failure to Provide and Communicate Baseline Care Plan to New Admission
Penalty
Summary
The deficiency involves the facility’s failure to provide a summary of the baseline care plan to a newly admitted resident and to ensure that the baseline care plan process was completed and documented as required. The resident’s EMR documented diagnoses of C. difficile and CHF. The Entry MDS was completed on the admission date, and the admission MDS was noted as in progress with no information available. A baseline care plan dated the day after admission documented contact precautions, including staff use of gowns and masks when changing contaminated linens and proper handling and bagging of soiled linens. However, during an interview several days after admission, the resident reported she did not know what a baseline care plan was, indicating that the plan had not been explained or summarized to her. Further observations and interviews showed additional failures in implementing and communicating the baseline care plan. On one occasion, the resident was heard yelling for help with her room door closed; when a nurse entered, the resident stated she wanted to get up but could not find her call light, which was observed on the floor under the bed. A nurse reported that the baseline care plan was started on the day of admission and that nurses would review it with the resident, but also stated that the charge nurse would not provide a written copy of the baseline care plan to the resident or family. An administrative nurse reported she would review the baseline care plan with the resident and/or family and claimed to have completed a 48-hour interdisciplinary care conference, but there was no opened or completed conference note in the EMR. She gave inconsistent explanations regarding who was responsible and why the conference note was missing. The facility did not provide a policy for baseline care plans.
Failure to Provide Accurate ADL Assessment and Timely Clothing Changes
Penalty
Summary
The facility failed to provide appropriate assistance with activities of daily living (ADLs), specifically dressing and clothing changes, for a resident with severe cognitive impairment. The resident had a diagnosis of dementia and repeated Brief Interview for Mental Status (BIMS) scores of one, indicating severe cognitive impairment. Despite this, both a Significant Change MDS and a Quarterly MDS inaccurately documented that the resident required only setup assistance with lower body dressing. The ADL Care Area Assessment did not trigger, and the resident’s care plan, revised on 03/23/26, inaccurately instructed staff that the resident was independent with dressing. The electronic medical record lacked staff documentation of the resident’s ADL needs, resulting in care instructions that did not reflect the resident’s actual functional status. On the day of observation, the resident was seen sitting in a wheelchair wearing black pants with food crumbs on them in the morning, and later was transported by a CNA to the dining room still wearing the same dirty pants. The pants were not changed until early afternoon, at which time two CNAs provided total assistance to change the dirty pants, and the resident was unable to participate in dressing or undressing. During interviews, the CNAs, a licensed nurse, and an administrative nurse all stated that residents should always be dressed in clean clothing and confirmed that this resident required total staff assistance with dressing. These observations and interviews showed that the resident’s actual need for total assistance with dressing and clothing changes was not accurately reflected in the MDS, care plan, or ADL documentation, and that the facility did not ensure the resident was kept in clean clothing as expected by facility policy for ADL care.
Failure to Maintain Safe Wheelchair Foot Positioning During Resident Transport
Penalty
Summary
The deficiency involves the facility’s failure to ensure an environment free from accident hazards and to provide adequate supervision during wheelchair transport for a resident with dementia. The resident’s EMR documented a diagnosis of dementia and a BIMS score of one on both a Significant Change MDS and a Quarterly MDS, indicating severe cognitive impairment. These MDS assessments inaccurately documented that the resident was independent with walking using a walker and/or wheelchair, and the ADL CAA did not trigger. The resident’s care plan, revised 03/23/26, identified cognitive impairment due to dementia but did not include instructions for staff on the use of wheelchair foot pedals while propelling the resident. On multiple observed occasions, staff propelled the resident in a wheelchair without maintaining his feet safely on the foot pedals. During transport from his room to the dining room, the resident’s left shoed foot fell from the foot pedal and skimmed the floor between the pedals, and later, during transport from the dining room to the shower room, both shoed feet skimmed the floor between the pedals. CNAs reported that the resident’s feet never stayed on the foot pedals and described the pedals as useless because he could not keep his feet on them. A licensed nurse confirmed the resident’s feet did not always remain on the foot pedals when staff propelled him and stated the pedals should be adjusted to better fit his needs. An administrative nurse stated it was the expectation that staff ensure the resident’s feet remained on the foot pedals during transport and that pedals should be lowered if needed. The facility did not provide a policy regarding wheelchair safety.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
