El Dorado Care And Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in El Dorado, Kansas.
- Location
- 900 Country Club Lane, El Dorado, Kansas 67042
- CMS Provider Number
- 175324
- Inspections on file
- 20
- Latest survey
- April 9, 2026
- Citations (last 12 mo.)
- 22
Citation history
Health deficiencies cited at El Dorado Care And Rehab during CMS and state inspections, most recent first.
Two residents experienced unmet nutritional needs when the facility failed to follow diet orders, monitor weight loss, and provide required meals. A resident with DM and a documented vegetarian diet order received regular diet meal tickets listing meat-based options, had poor intake of facility meals, and experienced a 16.3% weight loss in 19 days without timely documentation, provider notification, or initiation of nutritional interventions, despite policies requiring monitoring of impaired nutrition and unplanned weight loss. Another resident with ESRD on a therapeutic renal dialysis diet left very early for thrice-weekly dialysis and was not provided breakfast or alternative food to take, with EMR entries showing breakfast as not available or not applicable on dialysis days and staff confirming no meals or snacks were prepared, contrary to facility policies requiring at least three meals daily and coordination of nutritional management for dialysis care.
The facility failed to submit complete and accurate direct care staffing data to CMS via the PBJ system, resulting in reports that showed excessively low weekend staffing for multiple fiscal quarters. An administrative staff member acknowledged that a former business office manager had submitted the PBJ data incorrectly. This failure occurred despite a facility policy requiring uniform electronic submission of verifiable payroll data for all direct care staff, including agency and contract personnel, and specifying whether staff were employees or contracted workers.
Staff failed to follow the facility’s infection prevention and control policies, including Enhanced Barrier Precautions and hand hygiene, during care for multiple residents. CNAs performing peri-care and ostomy care used soiled gloves to open drawers, handle supplies, and apply barrier cream, did not change gloves appropriately, and did not perform hand hygiene after glove removal. Wound care consultants providing treatment to a resident’s foot wound used the same gloves to cleanse the wound and then handle clean dressings, the treatment cart, door handles, and the resident’s closet, and one consultant repeatedly removed and reapplied gloves to use a phone without hand hygiene. During wound care for a resident on EBP with a Foley catheter, colostomy, and hemodialysis port, several wound care staff wore gloves only and did not don required gowns, despite facility policy requiring gown and glove use for high-contact care of residents on EBP.
Surveyors observed that a resident’s Novolog insulin pen on a medication cart was in use without an open or discard date, and a treatment cart contained four expired stock medications (aspirin, vitamin D, calcium with vitamin D, and zinc). A CMA verified the medications were expired, and an LN acknowledged that staff were required to date insulin pens when opened. These findings showed that staff did not consistently label insulin pens or remove expired stock medications as required by the facility’s medication storage policy.
Surveyors identified multiple food service sanitation and hygiene deficiencies, including staff personal items and beverages placed on food prep counters next to unsealed and moldy bread products, missing temperature log entries for refrigeration units, and numerous undated, unsealed, or expired food items in the refrigerator, walk-in cooler, freezer, and dry storage. Food and canned goods were stored directly on the floor, and storage areas contained debris. Dietary staff entered the kitchen without hairnets, drank coffee in the kitchen near uncovered ready-to-serve food, used a single paper towel to wipe a thermometer between multiple food temperature checks, and reheated pureed food uncovered in the microwave, all contrary to facility policies on food safety, sanitation, and employee hygiene.
A resident repeatedly experienced his pants slipping down and exposing part of his buttocks while standing and walking in common areas, including the dining room and nurse’s station, requiring him to hold up his pants and leading another resident to comment on what she saw. Staff interviews indicated they were aware the clothing did not fit properly, and facility policy states residents must be treated with respect and dignity and that care should emphasize comfort and personal needs, including appropriate clothing.
A resident with chronic respiratory failure, tracheostomy, schizophrenia, and severely impaired cognition had an existing court-supported advance directive and DNR, documented in the EMR and signed by the guardian and a physician. During a mock survey, regional staff reportedly told facility staff the DNR was not valid because it was signed after guardianship paperwork, and the then-DON had the provider discontinue the DNR and change the resident’s status to full code. Subsequent provider orders and the care plan directed CPR and full-code measures, while notes and interviews showed staff confusion about the DNR’s validity and no follow-through by social services to assist the guardian in re-establishing the DNR, contrary to facility policy requiring that advance directives be respected and clearly documented.
A resident with chronic respiratory failure, schizophrenia, severe cognitive impairment, and total dependence for ADLs was observed with a red abrasion on the forehead that had not been documented in weekly skin assessments or progress notes. Staff had care plan instructions to inspect skin and report changes, but no documentation or investigation of the injury occurred until the next day, when an RN noted a purple abrasion of unknown origin and speculated the resident’s head may have contacted the wall after a room change. A CNA reported not noticing the abrasion, and an LN acknowledged being informed of the injury but failed to document it, assuming another nurse had done so, while administrative nursing staff were unaware of the injury.
A resident with anemia, CKD, DM, HTN, and major depressive disorder, who required extensive ADL assistance and used a wheelchair, was sent to the hospital after a critical Hgb result and provider direction to transfer. The record showed no written bed-hold notice or documentation of the facility’s bed-hold policy for this facility-initiated transfer, and staff confirmed that no such notice was given. The facility also lacked evidence that the State LTCO was notified of the resident’s transfer/discharge, and could not produce an Ombudsman notification policy, despite a written bed-hold policy requiring resident notification and filing of the bed-hold information in the medical record.
The facility failed to provide consistent bathing and grooming for several residents who required assistance with ADLs. One resident with cognitive impairment went extended periods without documented baths or showers despite a care plan requiring assisted bathing, and was observed with stained clothing and chin hair. Another resident with intact cognition, who preferred twice-weekly showers and staff-assisted shaving, lacked documentation of receiving the requested showers, appeared unshaven, and reported not getting showers while being told he had refused, with no refusal forms available. A third resident with severe cognitive impairment and total dependence for personal hygiene was repeatedly observed with facial hair and dirty, jagged fingernails despite care plans directing staff to assist with grooming. Staff interviews revealed inconsistent practices and confusion over who was responsible for shaving and nail care, contrary to facility policy requiring necessary services to maintain residents’ grooming and personal hygiene.
A resident with dementia, prior CVA, and ear malformation causing hearing impairment was care planned and ordered to use a right-ear hearing aid during the day, with staff responsible for ensuring its availability, function, and placement. Despite this, the resident was repeatedly observed without a hearing aid, and multiple CNAs and a CMA reported they had never seen one or were unaware of a care plan for its use. Activity and social services staff reported the hearing aid had stopped working months earlier, attempts to reach the DPOA about repair were unsuccessful, and no audiology visit was known to have occurred, while an RN later indicated a replacement hearing aid had been purchased and left charging at the nurse’s desk. The facility did not provide a policy governing hearing aid management.
A resident with Alzheimer’s disease, muscle weakness, and moderately impaired cognition, assessed as high risk for falls and dependent for transfers and toileting, experienced multiple falls in the dining room when staff did not consistently follow the fall-prevention care plan. The plan required non-slip footwear, not leaving the resident unattended in the dining room after meals, keeping the resident in a wheelchair rather than a dining chair, using an antithrust cushion with Dycem, and removing the Hoyer sling from the wheelchair after transfers. Fall investigations documented that the resident was found on the dining room floor on several occasions, including after not being offered toileting post-meal and when the lift sling had not been removed. Observations showed the resident being transported with the sling still under her and sling straps looped on wheelchair handles, while staff acknowledged the resident’s impulsivity and history of falls, demonstrating inadequate supervision and failure to implement care-planned interventions.
A resident with GERD, major depressive disorder, and protein calorie malnutrition, who was cognitively intact and independent with oral hygiene, developed tooth pain and a dental abscess that was treated only with antibiotics. Facility assessments documented tooth pain and abscessed teeth, but the care plan did not address broken or decayed teeth or specify dental services. Observation later revealed the resident had missing teeth, one decayed and split tooth, and another broken at the lower jaw. An administrative nurse acknowledged she had not assessed the resident’s mouth until the survey, confirmed the presence of two broken teeth, and verified the resident was not enrolled in the facility’s dental services and had received no dental care since admission, contrary to the facility’s routine dental care policy.
A resident did not receive timely or complete meals when dietary meal tickets failed to print and staff were unaware the meals were missing. On one morning, the resident waited in a wheelchair in her room well past normal breakfast time before receiving a tray with only cream of wheat and toast, without requested items such as eggs, orange juice, sugar, butter, or jelly. The previous evening’s supper had also been delayed for the same reason. Facility policy required that residents be provided palatable, attractive food at a safe, appetizing temperature and that food be prepared and served in compliance with safe food handling practices.
An administrative staff member misappropriated funds from three residents by writing checks on their personal accounts, forging signatures, and depositing the checks into her own bank account without proper written authorization. One affected resident had dementia with moderately impaired cognition and required assistance with most ADLs, and there was no documented authorization in the EHR for the facility to manage this resident’s funds. The staff member claimed the transactions were part of a Medicaid spend-down and that cash was placed in a facility safe or intended to be kept for the resident’s future use, but the checks were flagged by the bank’s fraud department, prompting the resident’s representative to confront the staff member. Subsequent review identified additional forged checks for two other residents, all in violation of facility policies prohibiting misappropriation and requiring written consent for management of resident funds.
A resident with paraplegia and other medical issues experienced a delay in surgery due to the facility's failure to obtain preoperative orders. The resident's surgery to close a PEG tube site was canceled and rescheduled because nursing staff did not receive or follow up on the necessary orders. Interviews revealed a lack of communication and follow-up, and the facility lacked a policy to ensure all components of planned procedures were in place.
Two residents requiring tracheostomy care in an LTC facility were found to have improperly stored suction tubing, with ends uncapped and placed directly in drawers with other supplies. This practice violated the facility's policy for maintaining sterile conditions, posing a risk of infection. Staff acknowledged the tubing should have been capped and stored properly to prevent contamination.
A resident with heart failure received Metoprolol outside prescribed parameters on multiple occasions without physician notification. The resident also refused the medication several times, with no documentation of physician notification or education on risks and benefits. Staff interviews confirmed the need to follow physician orders, but the facility lacked a policy for handling such situations.
The facility failed to prevent foodborne illness by not adhering to food safety and sanitation policies. Observations revealed uncovered condiment bottles, a dirty handwashing sink, a splattered air fryer, and an improperly drained ice machine. Staff confirmed these issues, indicating non-compliance with facility policies.
A facility failed to ensure proper infection control during incontinence care for a resident with a sacral pressure ulcer. The resident, with a history of diabetes, heart failure, and cerebral infarction, required substantial assistance and was incontinent. During care, a CNA improperly wiped from the rectum over the wound, contrary to infection control practices. The facility's policy required care that promotes healing, which was not followed, leading to a deficiency.
The facility failed to maintain safe patient care equipment for two residents. An over-the-toilet commode was found to be unstable, and commode grab bars were not securely fixed, posing a risk during use. The facility lacked a specific maintenance policy for these items, contributing to the deficiency.
The facility failed to ensure that three residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and/or the residents' choices, specifically related to skin treatments for ostomies. Dressings for suprapubic catheters and a gastrostomy tube were not changed as ordered by the physician, and the facility lacked policies to address these issues.
The facility failed to ensure that three residents received treatment and care in accordance with physician's orders related to skin treatments for ostomies and gastrostomy tubes. Dressings were not changed as ordered, and concerns were not adequately addressed by the administrative staff.
Failure to Provide Ordered Vegetarian Diet, Address Significant Weight Loss, and Serve Breakfast on Dialysis Days
Penalty
Summary
The deficiency involves the facility’s failure to meet residents’ nutritional needs by not honoring a prescribed vegetarian diet and not responding to significant weight loss for one resident, and by not providing breakfast meals on dialysis days for another resident. One resident with diabetes mellitus was admitted for IV antibiotic therapy after a recent UTI and was identified as at risk for dehydration and nutritional issues. Her baseline care plan and physician orders documented a vegetarian diet, regular texture, and thin liquids, and the care plan instructed staff to monitor and record meal intakes, obtain RD evaluation as needed, and complete weekly weights. Despite this, her MDS showed she did not receive a therapeutic diet, and her meal tickets were printed as a regular diet with meat-based options such as chicken, cheeseburger, hot dog, and sloppy joe, and no vegetarian menu was available. Dietary staff acknowledged they did not have a vegetarian meal ticket for her and had not yet ordered soy burgers, and staff reported difficulty providing her vegetarian diet due to lack of appropriate choices. The same resident’s intake of facility-provided meals was documented as poor, less than 50% of meals, and she was described as very particular about what she ate, with her husband frequently bringing in outside food of unknown amounts. Weights documented in the EMR showed 156.2 lbs on admission and again on a later date, followed by a drop to 132.8 lbs and then a calculated weight of 128.4 lbs when the wheelchair weight was subtracted, representing a significant weight loss of 16.3% in 19 days. The EMR lacked a progress note addressing the weight loss on the date it was first recorded, and nursing documentation showed that when the provider was in the facility shortly after the low weight was obtained, staff updated the provider about low blood pressure but not about the weight loss. The provider was not documented as being notified of the weight loss until several days later, and there was no evidence of re-weighing, appetite stimulant orders, or nutritional supplements being initiated despite existing orders allowing the RD or interdisciplinary team to start supplements. Administrative and dietary staff later reported they were unaware of the weight loss at the time and had not reviewed the resident’s weights. The deficiency also includes failure to provide breakfast meals to another resident with ESRD and moderate protein-calorie malnutrition who received dialysis three times per week. This resident had a therapeutic renal dialysis diet ordered and required set-up assistance for eating, with documentation that his meal intakes were generally good and adequate to meet estimated needs. His EMR showed multiple breakfast meal entries on dialysis days marked as “not available” or “not applicable,” and staff interviews revealed that he left very early for dialysis and was not provided breakfast or a snack to take with him. The resident reported he did not eat breakfast before dialysis because none was provided, and he did not receive a snack at the dialysis center. CNAs and an LN confirmed that no actual breakfast meal was prepared for him on dialysis mornings, the kitchen was closed at the time he woke up, and no alternative food or drinks were offered to take with him. The facility’s own policies on dialysis care and frequency of meals required communication about nutritional management and provision of at least three meals daily at regular times or according to resident needs and care plan, but these were not followed for this resident on dialysis days. The facility’s Nutrition (Impaired)/Unplanned Weight Loss clinical protocol required monitoring and documenting weight and dietary intake in a way that allowed ready comparison over time, defining current nutritional status through interdisciplinary assessment, and using supplementation strategies such as food fortification and increased portions for residents with impaired nutrition or risk factors. For the resident with significant weight loss and a vegetarian diet order, the record and interviews showed that although poor intake and vegetarian preference were known, the facility did not adjust menus to provide appropriate vegetarian options, did not consistently document or act on poor intake, and did not promptly assess or intervene when substantial weight loss occurred. For the resident on dialysis, the facility’s Dialysis, Care for a Resident policy required communication about nutritional and fluid management, and the Frequency of Meals policy required at least three meals or their equivalent daily, but staff acknowledged that no breakfast meal or equivalent was prepared or offered on dialysis mornings, and refusals were not documented in the EMR or care plan.
Inaccurate PBJ Submission Resulting in Underreported Weekend Staffing
Penalty
Summary
The facility failed to electronically submit complete and accurate direct care staffing information to CMS through the Payroll Based Journal (PBJ) system as required, resulting in reported staffing levels that did not reflect actual staffing. CMS PBJ reports for Fiscal Year 2026 Quarter 1 and Fiscal Year 2025 Quarter 3 showed excessively low weekend staffing, indicating that the data submitted did not accurately capture direct care staff hours. During an interview, an administrative staff member acknowledged awareness of a problem and reported that the previous Business Office Manager had submitted the PBJ information incorrectly. The facility’s own PBJ F851 policy required submission of payroll data in a uniform CMS-specified format for all direct care staff, including community, agency, and contract staff, and required that the data distinguish between employees and contracted or agency staff, but this policy was not followed, leading to incomplete and inaccurate staffing information being reported.
Failure to Follow Enhanced Barrier Precautions and Hand Hygiene During Resident Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, including Enhanced Barrier Precautions (EBP) and hand hygiene, during resident care. Surveyors observed two CNAs providing perineal care to a resident when one CNA used the same soiled gloved hand that had been used for peri-care to open a drawer, remove barrier cream, and apply it to the resident’s buttocks. The same CNA then removed her gloves and applied a new pair without performing hand hygiene. The second CNA did not change gloves after cleansing a small, soft bowel movement and continued assisting the resident with clothing, then removed her soiled gloves, did not perform hand hygiene, touched the doorknob, exited and re-entered the room, and applied new gloves. In interviews, both CNAs stated they did not realize they were required to wash their hands after removing soiled gloves and did not realize they had used soiled gloved hands to open drawers and apply barrier cream. In a separate observation, one of the same CNAs provided ostomy care to another resident by removing the ileostomy bag and wafer, cleansing around the stoma, and then using the same soiled gloves to open a box of ostomy supplies, remove a new bag/wafer, and apply it to the resident’s abdomen. The CNA then opened a drawer with gloved hands to obtain wipes and barrier cream, applied new gloves, opened the bathroom and closet doors, removed a brief, cleansed the resident’s buttocks, and applied barrier cream. Afterward, the CNA removed her gloves and assisted the resident with her brief without performing hand hygiene. The assisting CNA also removed her gloves, failed to perform hand hygiene, applied new gloves, and opened the closet door to remove the resident’s clothes. In interviews, both CNAs acknowledged they did not realize they had to wash their hands when removing gloves during care and that they had used soiled gloved hands to open drawers and closets and to handle supplies. Additional deficiencies were observed during wound care for another resident and during wound care for a resident on EBP. A wound care consultant removed soiled dressings from a resident’s right foot and great toe, removed her gloves, and then applied new gloves without hand hygiene. Another consultant cleansed the open wound using a 4x4 gauze without flipping it, kept the same gloves on, and then handled clean dressings, the treatment cart, and door handles with those gloves. The primary consultant intermittently removed one glove to use her phone for wound measurements and photographs, reapplied gloves without hand hygiene, and continued wound care. The second consultant continued to wear the same gloves used to clean the wound while opening drawers on the treatment cart, entering the resident’s closet to obtain dressings, and wiping down the treatment cart. In a separate observation, multiple wound care consultants provided wound care to a resident on EBP who had a Foley catheter, colostomy, and hemodialysis port, but none wore gowns as required; all wore gloves only. Interviews with the wound care consultants and the facility’s infection preventionist confirmed that gowns and gloves were required for residents on EBP and that staff were expected to perform hand hygiene after glove removal and avoid touching clean items or residents with soiled gloves, consistent with the facility’s EBP and hand hygiene policies.
Failure to Label Insulin Pen and Remove Expired Stock Medications
Penalty
Summary
Surveyors found that the facility failed to properly label and store medications and biologicals as required by facility policy and professional standards. During observation of the 100–200 hall medication cart at 8:05 AM, an insulin pen (Novolog) for Resident 41 was found without an open date or discard date. In a separate observation of the treatment cart at 8:15 AM, four bottles of stock medications were found to be expired: aspirin 325 mg (expired 01/26), vitamin D tablets (expired 03/26), calcium 600 mg with vitamin D 5 mcg (expired 07/25), and zinc 50 mg tablets (expired 01/26). A certified medication aide confirmed that the stock medications were expired, and a licensed nurse confirmed the insulin pen was undated and stated that staff were supposed to date insulin pens when opened. The facility’s Medication Storage policy, dated 03/2026, stated that all drugs and biologicals would be stored in a safe, secure, and orderly manner and that discontinued, outdated, or deteriorated drugs or biologicals would not be used and would be returned to the pharmacy or destroyed per state regulations. These observations and staff confirmations demonstrated that the facility did not ensure insulin pens were dated when opened and did not remove expired stock medications from use, contrary to its own policy and accepted standards for medication storage and labeling.
Food Service Sanitation and Hygiene Deficiencies in Dietary Department
Penalty
Summary
The deficiency involves failure to prepare and serve food under sanitary conditions and in accordance with professional standards. Surveyors observed staff personal items, including a purse and a drink tumbler with a straw, placed on a kitchen prep counter next to undated and unsealed hamburger and hot dog rolls, one bag of which contained rolls with fuzzy green mold. On the same counter, there were unsealed and undated bags of potato chips. Temperature logs for the kitchen refrigerator, walk-in cooler, and walk-in freezer had missing entries on multiple dates, despite expectations that temperatures be recorded at least daily or three times a day. In the kitchen refrigerator, surveyors found wilted lettuce in an unsealed bag, undated opened beef base, undated mustard and relish, unsealed and undated deli meats, and opened honey-thickened liquids dated beyond the manufacturer’s seven-day discard timeframe, along with undated cottage cheese and salsa. In dry storage, surveyors identified a dented can of cheese sauce in the front rotation of canned items, a box of gravy mixes and large cans of apple pie filling stored directly on the floor, and multiple unsealed dry products including rice cereal, spaghetti, and lasagna noodles. In the walk-in cooler, temperature logs again lacked entries for several days, and food items such as celery, wilted lettuce, a bowl of batter covered with foil but not labeled, unsealed sausage patties, a large container of egg salad dated beyond seven days, a loosely covered pastry, and an unlabeled container of meat in brown fluid were observed. In the walk-in freezer, boxes and bags of meat were stored directly on the floor, the internal thermometer was found on the floor, and the cooler and freezer floors contained significant debris that appeared to be old food crumbs. These conditions were inconsistent with facility policies requiring food to be stored off the floor, properly labeled, dated, sealed, and discarded when outdated, wilted, or moldy, and requiring clean storage areas. Additional deficiencies were observed in staff hygiene and food handling practices. One dietary staff member drank coffee in the kitchen and placed the cup on a counter next to an uncovered, ready-to-serve cake, and reported that he routinely drank coffee while working in the kitchen. The same staff member used a single paper towel to wipe a thermometer between multiple food temperature checks and later reported this was his usual practice, despite expectations to properly sanitize the thermometer after each use. He also reheated pureed food in the microwave uncovered, contrary to facility expectations. Another dietary staff member entered the kitchen multiple times without a hairnet before being instructed to put one on, and later acknowledged she should have applied it before entering. These practices conflicted with facility policies on employee hygiene, hair restraint use, prohibition of eating and drinking in food preparation areas, and proper sanitation of equipment and utensils.
Failure to Maintain Resident Dignity When Clothing Did Not Fit Properly
Penalty
Summary
The deficiency involves the facility’s failure to maintain resident dignity by allowing a male resident’s pants to repeatedly fall and expose his buttocks in common areas without effective intervention. On one observed occasion during meal service at 11:55 AM, the resident stood up from the dining table and, as he began to walk, his pants fell below his abdomen, exposing the top of his buttocks. The resident had to grab the waistband of his pants to hold them up, and another elderly female resident verbally remarked that she had seen his buttocks. On another observed occasion at 12:10 PM, the same resident was at the nurse’s station on the phone when his plaid pajama pants slipped below his abdomen, exposing approximately a quarter of his buttocks. As he walked to the dining room, he continued to pull up his pants in an attempt to keep them from falling. During an interview on 06/08/26 at 11:00 AM, a licensed nurse stated that the resident had not experienced weight loss and she did not know why his clothes were not fitting correctly. The facility’s policy on Respect and Dignity, Right to Personal Property, Including Searches and Illegal Substances, dated 06/25, states that residents have the right to be treated with respect and dignity and that staff shall provide person-centered care emphasizing residents’ comfort, independence, and personal needs and preferences, including accommodation of personal clothing unless it infringes on others’ rights or safety. The repeated exposure of the resident’s buttocks in public areas, observed by other residents, occurred despite this policy and constituted a failure to promote and protect the resident’s dignity.
Failure to Honor a Resident’s Existing DNR and Advance Directive
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s existing do not resuscitate (DNR) order and advance directive. The resident had chronic respiratory failure, a tracheostomy, schizophrenia, severely impaired cognition, and required total assistance with all activities of daily living. The resident was nonverbal, rarely communicated, and was dependent on staff for all care. Court documentation under Kansas law authorized the guardian and conservator to consent on the resident’s behalf to the withholding of life-saving medical care, treatment, services, or procedures. The resident’s electronic medical record contained an uploaded DNR document signed by one physician, the guardian, and two witnesses, and the physician orders initially documented a DNR status from admission. Despite this, the resident’s DNR order was discontinued on a later date and replaced with a physician order for full code, all measures. The care plan was updated to instruct staff to initiate CPR when appropriate and continue until paramedics arrived. Provider notes showed conflicting documentation, with one note listing the code status as DNR and a later note documenting that the DON notified the provider that the resident required a DNR form in the chart. The provider then ordered the resident to be full code until two physicians could sign a form stating the resident was a DNR candidate and the durable power of attorney would work through the court process, and a progress note recorded that the code status was updated to full code pending completion of this process. Interviews and record reviews revealed confusion among staff regarding the validity of the DNR and the impact of guardianship paperwork. The social services designee reported that during a mock survey by regional staff, she was told the resident’s DNR was not valid because it was signed after the guardianship paperwork was in effect, and that the then-DON had the provider discontinue the DNR. She also stated she had not spoken with the guardian about a request for assistance in completing a DNR. The guardian reported that the resident used to be a DNR, that an audit required a change to full code, and that he did not understand why and had asked the facility for assistance. Administrative staff later reviewed the EMR, DNR, progress notes, orders, and guardianship paperwork and stated they had no prior knowledge of the guardian’s concern, even though facility policy required that advance directives be respected and prominently displayed in the medical record.
Failure to Identify and Document Forehead Abrasion of Nonverbal Resident
Penalty
Summary
The deficiency involves the facility’s failure to identify, monitor, and respond to an injury of unknown origin on a resident’s forehead. The resident had chronic respiratory failure, schizophrenia, was nonverbal, rarely communicated, and was assessed as having severely impaired cognition, requiring total assistance for all ADLs and having no documented behaviors. The care plan directed staff to inspect the resident’s skin weekly and as needed, observing for redness, open areas, scratches, cuts, and bruises, and to report any changes to the nurse. Weekly skin notes for the period reviewed did not document any abrasion or bruise to the forehead. On the first day of the annual survey, the resident was observed in bed with a red abrasion on the right side of the forehead measuring approximately 0.5 cm by 2 cm. When asked if he had a fall, the resident shook his head side to side indicating no. The resident’s progress notes contained no evidence that staff had identified the forehead abrasion or investigated its origin until the following day, when a note documented a purple abrasion on the right forehead measuring 0.3 cm by 2.5 cm by 0 cm, with the resident unable to describe how it occurred. Staff reported no known event, and the note suggested the resident’s head may have hit the wall during cares after a recent room change that placed the bed against the wall, with a fall mat on the left side of the bed. A CNA who provided care reported she had not noticed the abrasion/redness and stated that any new skin issue should be reported to the nurse and that staff were required to write a statement for injuries such as bruises or skin tears. An LN reported being told by the night nurse that the resident had an abrasion but did not document it, assuming the night nurse had done so. An administrative nurse stated she was not aware of the abrasion and that the nurse should have reported, assessed, and completed risk management and a root cause analysis for the abrasion.
Failure to Provide Bed-Hold Notice and Ombudsman Notification for Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to provide required written notification of its bed-hold policy and to notify the State Long Term Care Ombudsman when a resident was transferred to the hospital. The resident had multiple diagnoses including anemia, chronic kidney disease Stage 3, DM, HTN, and major depressive disorder, and required substantial assistance with ADLs, used a wheelchair with setup assistance, and was identified as a fall risk. The resident’s care plan included monitoring for changes in mental status, lethargy, fatigue, tremors, seizures, breathing difficulties, and monitoring labs and electrolytes related to renal insufficiency. On one occasion, a critical hemoglobin value of 6.1 g/dl was reported by the lab, and the provider instructed staff to send the resident to the emergency room, after which the resident left the facility by ambulance and later returned from the hospital with end stage renal disease and anemia. Record review showed the resident’s clinical record lacked evidence of a bed-hold notice or bed-hold policy documentation related to this facility-initiated transfer to the hospital, and the facility was unable to provide such evidence upon request. The facility also could not provide evidence that the State LTCO was notified of the resident’s transfer/discharge to the hospital. During an interview, a social services staff member confirmed that there was no bed-hold notice for the resident’s hospital transfer and that the Ombudsman had not been notified. The facility’s own bed-hold policy required staff to inform residents upon admission and prior to transfer for hospitalization (including after emergency transfers, per state law) about the bed-hold policy and to file a copy of the resident’s bed-hold policy in the medical record, but this was not documented for the resident. The facility was also unable to provide an Ombudsman Notification policy upon request.
Failure to Provide Consistent Bathing and Grooming for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide consistent bathing and grooming for multiple residents who required assistance with activities of daily living. One resident with Alzheimer’s disease, anxiety, and atrial fibrillation had a BIMS score indicating moderately impaired cognition and required staff assistance with showers and personal hygiene. Her care plan directed staff to assist with bathing using a shower chair. However, shower records showed she did not receive a bath or shower for extended periods in March and early April, with only a few refusals documented despite staff statements that she frequently refused. Observations noted stained clothing and multiple chin hairs, and interviews with CNAs and nursing staff revealed inconsistent documentation practices and uncertainty about what happened to shower sheets after they were completed. Another resident with benign prostatic hyperplasia, major depressive disorder, and polyneuropathy had intact cognition and required supervision with showers and personal hygiene. His care plan documented a preference for staff-assisted shaving and two showers per week on specific days. Monthly shower sheets and bathing records for February and March lacked documentation that he received the requested twice-weekly showers and did not show refusals. During observation, he was unshaven and reported not receiving showers as requested, stating staff told him he had refused, but he was unable to review any signed refusal documentation. Staff interviews indicated he did not typically refuse showers and suggested that the bath aide was sometimes reassigned to floor duties, which may have contributed to missed showers. A third resident with dementia and a history of cerebral infarction had severely impaired cognition, relied on staff to meet daily needs, and required total assistance for personal hygiene per MDS and care plan documentation. Care plans directed staff to assist with grooming and hygiene to the extent needed. On multiple observations over two days, this resident was noted to have several chin hairs approximately 0.25 inches long and fingernails with a brown substance underneath and jagged edges, with no change after morning care was provided. Interviews with CNAs and a nurse revealed inconsistent understanding of responsibilities for shaving and nail care, with some CNAs reporting they were taught not to shave residents and that nurses cut nails, while the administrative nurse stated CNAs were expected to file, clean, and trim fingernails (except for diabetic residents) and remove facial hair on shower days and as needed. These findings conflicted with the facility’s Quality of Life–Activities of Daily Living policy, which required necessary care and services to maintain residents’ grooming and personal hygiene.
Failure to Ensure Resident Access and Assistance With Prescribed Hearing Aid
Penalty
Summary
The facility failed to ensure that a dependent resident received staff assistance with the use of a prescribed hearing aid. The resident’s EMR documented dementia with severely impaired cognition, a history of cerebral infarction, and an ear malformation causing hearing impairment. A Significant Change MDS and subsequent Quarterly MDSs showed the resident wore a hearing aid and relied on staff to have needs met, with no change in hearing aid use. The resident’s care plan directed staff to ensure availability and functioning of adaptive communication equipment, including a right-ear hearing aid to be worn during the day, removed at night, and stored and charged at the nurses’ station. Physician orders allowed for specialist care, including an audiologist, as needed. Activity notes documented that the resident was hearing impaired and wore a right-ear hearing aid when available, and that the resident had limited communication. During multiple observations, the resident was seen in a wheelchair and in the dining room without a hearing aid in place. Multiple CNAs and a CMA reported they had never seen the resident with a hearing aid and did not know if the resident was care planned for one. The Activity Director and Administrative Nurse F gave conflicting information, with the Activity Director initially stating the resident did not have a hearing aid and staff had to speak loudly in the resident’s right ear, and later stating the hearing aid had stopped working and would not hold a charge. The Social Service Designee reported the hearing aid had broken months earlier, that attempts to contact the resident’s durable power of attorney about repair had been unsuccessful, that she was unsure about coverage or personal funds for repair, and that she did not think the resident ever had an audiology appointment. Administrative Nurse D stated she expected staff to ensure hearing aids were offered and placed as ordered and reported that an unnamed nurse had purchased a hearing aid for the resident, which had been at the nurse’s desk charging. The facility did not provide a policy for hearing aids.
Failure to Follow Fall-Prevention Care Plan and Supervise High-Risk Resident in Dining Room
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and maintain a safe environment for a resident with a known high risk for falls, particularly in the dining room. The resident had diagnoses including Alzheimer’s disease, anxiety, atrial fibrillation, and muscle weakness, with a BIMS score of 8 indicating moderately impaired cognition. Assessments documented that the resident required partial staff assistance for eating and mobility, was dependent for transfers and toileting, did not ambulate, and had been identified as high risk for falls on multiple fall assessments. The care plan contained specific fall-prevention interventions, including ensuring non-slip footwear, use of a floor mat by the bed, not leaving the resident unattended in the dining room after meals, keeping the resident in the wheelchair rather than transferring to a dining chair for meals, use of an antithrust cushion with Dycem in the wheelchair, and removal of the Hoyer sling from the wheelchair after transfers. Despite these identified risks and documented interventions, the resident experienced multiple falls in the dining room. A fall on 12/21 was documented after the resident had been one-on-one all afternoon due to attempts to stand and walk and expressing a desire to go home; staff later found the resident on the dining room floor. A subsequent fall on 03/11 occurred when another resident called for help and staff found the resident seated on the floor in front of the wheelchair; the investigation identified that the sling from the mechanical lift had not been removed after transfer, and this was determined to be the root cause of that fall. Another fall on 03/28 occurred when the resident was found lying face down on the floor with the wheelchair at her feet, and documentation noted that the resident needed to go to the bathroom after a meal and had not been offered toileting. Observations and staff interviews further showed that the facility did not consistently follow the resident’s care plan interventions. On 04/06, the resident was observed being pushed to the dining room in a wheelchair with the sling still under her, contrary to the care plan directive to remove the sling after transfer. On 04/07, a CNA was observed leaving the sling partially under the resident in the wheelchair and looping the sling straps around the wheelchair handles after using the Hoyer lift. Staff, including a CNA and a licensed nurse, acknowledged that the resident was impulsive, had multiple falls, and required close observation. An administrative nurse stated that the resident should not have been left alone in the dining room because of her impulsivity and history of falls and that staff were expected to follow the care plan. The facility’s fall policy required review of the care plan and evaluation of the circumstances of falls to determine causes and implement appropriate interventions to prevent further falls, but the repeated falls and observed practices demonstrated that key care plan interventions were not consistently implemented.
Failure to Facilitate Necessary Dental Services for a Resident with Abscessed and Broken Teeth
Penalty
Summary
The facility failed to provide necessary routine and 24-hour emergency dental care for a resident who required dental services. The resident’s EMR documented diagnoses of GERD, major depressive disorder, and protein calorie malnutrition, with an admission MDS showing intact cognition and independence with oral hygiene. Initial assessments recorded that the resident did not have natural teeth or dentures and had recent weight loss, but lacked further dental documentation. A Dental Care CAA later recorded tooth pain on the right side and initiation of an antibiotic for a dental abscess. Nursing notes documented the resident’s report of a tooth abscess, mouth soreness, and pain, followed by an order for Clindamycin 300 mg four times daily for seven days and continued antibiotic treatment for abscessed teeth. Despite these documented dental issues and the facility’s Routine Dental Care policy requiring ongoing assessments, physician notification, and dental consultation as appropriate, the resident’s care plan contained no reference to broken or decayed teeth or to dental services to be provided. Observations showed the resident eating with missing teeth, one decayed and split tooth, and another broken off at the lower jaw. The Administrative Nurse confirmed she had not visualized the resident’s mouth or teeth until the survey date, verified the resident was edentulous except for two broken teeth, and acknowledged the resident was not on the facility’s dental services and had not received any dental care or services since admission, despite the facility’s policy outlining initial evaluation of dental needs, consultation with a dental consultant, and a daily oral hygiene plan of care.
Failure to Provide Timely and Complete Meals Due to Missing Dietary Tickets
Penalty
Summary
The facility failed to meet residents' nutritional needs in accordance with established national guidelines when a resident did not receive timely and complete meals due to errors in the dietary ticketing and delivery process. On the morning of 04/06/26, the resident was observed sitting in a wheelchair in her room at 9:00 AM with her bedside table in front of her, waiting for her breakfast tray. At 9:30 AM, a nurse aide informed her that the kitchen had not yet delivered the food cart to the hall and that her tray would be delivered once it arrived. By 10:00 AM, the resident was still waiting for breakfast. When questioned at 10:05 AM, Administrative Nurses D and E acknowledged that the resident should have received breakfast before 10:00 AM. At 10:10 AM, the resident finally received a tray containing cream of wheat and one piece of toast, without sugar, butter, or jelly. The resident reported that she had requested eggs and orange juice but was told by staff that those items were unavailable and that what she received was all that was available. Administrative Nurse E verified that the kitchen had not printed a breakfast ticket for the resident, which resulted in her not receiving her meal on time. Dietary Staff BB later confirmed that the resident had not received her breakfast tray because the meal ticket did not print and also verified that the resident’s supper meal the previous evening had been delayed for the same reason. The facility’s Food Preparation and Service policy, dated 10/2025, states that residents are to be provided with food that is palatable, attractive, and at a safe and appetizing temperature, and that food service employees should prepare and serve food in a manner that complies with safe food handling practices.
Misappropriation of Resident Funds Through Unauthorized Checks and Forged Signatures
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from misappropriation of their personal funds when an administrative staff member wrote checks and forged signatures on resident accounts without proper authorization. One resident had dementia with moderately impaired cognition, required assistance with most ADLs, and had a documented diagnosis of dementia. This resident’s EHR did not contain any written authorization from the resident or the resident’s representative allowing the facility to manage personal funds, as required by facility policy. Despite this, an administrative staff member assumed responsibility for the resident’s finances and engaged in financial transactions on the resident’s behalf. According to the facility’s investigation notes and staff and representative statements, the resident’s representative was contacted by the bank’s fraud department about suspicious checks drawn on the resident’s account and deposited into the administrative staff member’s personal account. The administrative staff member stated she had written a large check in the past to apply toward the resident’s liability to the facility and later wrote two additional checks for several hundred and over one thousand dollars each, made out to the facility in care of herself. She reported that she deposited these checks into her personal bank account, then took cash to the facility and placed it in a safe, claiming it was part of a spend-down process to help the resident qualify for Medicaid and to provide the resident with money after Medicaid started. The resident’s representative reported that the administrative staff member admitted depositing the checks into her personal account and said she planned to keep the money in a closet and return it to the resident after Medicaid began. Further review by the facility revealed two additional instances in which the same administrative staff member forged signatures to cash checks belonging to two other residents, resulting in misappropriation of smaller amounts from their accounts. The facility’s policies on abuse prevention and management of residents’ personal funds stated that residents have the right to be free from misappropriation of property and that any management of resident funds by the facility must be authorized in writing and documented in the resident’s EHR. In these cases, checks were written, signatures were forged, and resident funds were deposited into a staff member’s personal account without appropriate written authorization or adherence to the facility’s stated procedures for handling resident funds.
Failure to Ensure Preoperative Orders Delays Resident's Surgery
Penalty
Summary
The facility failed to ensure that a resident received appropriate preparations for a scheduled surgery, which resulted in the surgery being delayed. The resident, who had paraplegia and other medical issues, was dependent on staff for activities of daily living. The resident was scheduled for surgery to close a PEG tube site, but the nursing staff did not receive or follow up on preoperative orders from the physician's office. This oversight led to the resident refusing to take his blood thinner, causing the surgery to be canceled and rescheduled for a later date. Interviews with facility staff revealed a lack of communication and follow-up regarding the preoperative orders. A CNA was aware of the need for transportation for the surgery but assumed the nursing staff had the necessary orders. Administrative nurses confirmed that the nursing staff did not prepare the resident for surgery due to not ensuring the receipt of preoperative orders. The facility lacked a policy to ensure that all components of planned operative procedures were in place, contributing to the delay in the resident's surgery and progress toward returning home.
Improper Storage of Suction Equipment Leads to Deficiency in Respiratory Care
Penalty
Summary
The facility failed to provide appropriate respiratory care for two residents, R27 and R3, who required tracheostomy care and tracheal suctioning. Both residents had severe cognitive impairments and were unable to communicate effectively. R27 had a history of spastic quadriplegia, cerebral palsy, chronic respiratory failure with hypoxia, and pneumonia, while R3 had chronic respiratory failure, COPD, and was a carrier of MRSA. The care plans for both residents directed staff to monitor for respiratory infections and ensure proper storage of suctioning equipment to prevent contamination. Observations revealed that the suction tubing for both residents was improperly stored, with the ends uncapped and placed directly on the bottom of drawers alongside other medical supplies. This practice was inconsistent with the facility's policy, which required sterile equipment to prevent infection. Licensed nurses and administrative staff acknowledged that the tubing should have been capped and stored properly to prevent contamination and cross-contamination. The facility's failure to adhere to professional standards of practice regarding the storage of suctioning equipment led to a deficiency in providing necessary respiratory care. The improper storage of suction tubing posed a risk of infection and cross-contamination, which was not in line with the facility's policy for maintaining sterile conditions during tracheostomy care and suctioning procedures.
Failure to Monitor and Administer Heart Failure Medication Correctly
Penalty
Summary
The facility failed to ensure that medications were monitored and administered correctly for a resident with heart failure. The resident, who was cognitively intact but experienced a decline in cognition, was prescribed Metoprolol Succinate ER to manage heart failure. The physician's orders specified that the medication should be held if the resident's systolic blood pressure (SBP) was less than 110 or if the pulse was less than 60. However, the resident received the medication outside of these parameters on five occasions, and there was no documentation of physician notification for these instances. Additionally, the resident refused the medication on five separate occasions, yet there was no evidence of physician notification or documentation of education provided to the resident regarding the risks and benefits of taking the medication. Interviews with facility staff revealed that the resident frequently refused medication, often due to being agitated when woken up. The licensed nurse confirmed that the medication should be held and the physician notified if vital signs were outside the prescribed parameters. The administrative nurse reiterated that staff should follow physician orders and notify the physician when necessary. The facility lacked a policy to address the administration of medications according to physician orders and the notification of physicians regarding parameter outliers and resident refusal of medication.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure that foods were stored, prepared, and distributed in a manner to prevent foodborne illness to the residents. During an observation, it was noted that the kitchen refrigerator contained six squirt bottles of condiments, such as salad dressings, which lacked coverings over the tips. Additionally, during an environmental tour of the kitchen, several areas of concern were identified: the kitchen handwashing sink had a black substance along the back edge caulking and brown/yellow discolorations on the sink back edges; the air fryer/convection oven had splatters of a black substance on the upper interior surface; and the ice machine drain was directly in the drain without a two-inch air gap. Dietary Staff BB confirmed these issues, and Maintenance Staff U confirmed the lack of a two-inch air gap for the ice machine drain. The facility's policies on food safety and sanitation were not adhered to, as foods stored in the refrigerators were not covered, labeled, and dated, and the food service area was not maintained in a clean and sanitary manner.
Infection Control Deficiency in Incontinence Care
Penalty
Summary
The facility failed to ensure proper infection prevention and control during incontinence care for a resident with an open wound on her sacrum. The resident, who had a history of diabetes, heart failure, cerebral infarction, and a stage two pressure ulcer, required substantial assistance with activities of daily living and was incontinent of bowel and bladder. During an observation, a Certified Nurse Aide (CNA) and an Administrative Nurse provided incontinence care to the resident. The CNA used peri wipes to cleanse the rectal area of stool, and upon instruction, removed the soiled dressing from the sacral wound. However, the CNA then wiped the resident from the rectum over the wound, which was not in accordance with proper infection control practices. The facility's policy on wound care guidelines instructed staff to provide care that promotes healing, which was not adhered to in this instance. The Administrative Nurse acknowledged that staff should wipe incontinent residents from front to back and, in this case, should have wiped away from the wound to prevent contamination with stool. This failure to follow appropriate incontinence care procedures resulted in a deficiency in infection prevention and control for the resident with a sacral pressure ulcer.
Unsafe Patient Care Equipment
Penalty
Summary
The facility failed to maintain patient care equipment in safe operating conditions for two residents. During an observation, it was noted that the over-the-toilet commode used by one resident had four legs that wobbled when pressure was applied to the armrests, rendering it unstable. Additionally, the commode grab bars in another resident's bathroom were found to be unstable and moved when the resident attempted to sit or rise from the commode. An interview with administrative staff revealed that there was an expectation for staff to enter maintenance requests into their electronic system for such tasks. However, the facility lacked a policy specifically for the maintenance of commode grab bars and over-the-toilet commodes, leading to the failure to ensure these items were maintained in a safe condition to prevent accidents.
Failure to Change Dressings as Ordered
Penalty
Summary
The facility failed to ensure that three residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and/or the residents' choices, specifically related to skin treatments for ostomies. Resident 2, who had a suprapubic catheter, did not have their dressing changed as ordered by the physician. The dressing, dated 03/12/24, was not changed on 03/13/24 by the night shift nurse, who was an agency nurse. This failure was confirmed by multiple licensed nurses and the administrative nurse, who acknowledged that the night shift nurse was responsible for changing the dressing nightly. The facility lacked a policy to address changing dressings for suprapubic catheter insertion sites to prevent infections and maintain skin integrity. Resident 3, who also had a suprapubic catheter, experienced a similar issue. The dressing dated 03/12/24 was not changed on 03/13/24 by the night shift nurse. Licensed nurses confirmed that the night shift nurse should have changed the dressing as ordered by the physician to prevent infection and monitor the skin for breakdown. The facility again lacked a policy to address changing dressings for suprapubic catheter insertion sites. Resident 4, who had a gastrostomy tube, did not have their dressing changed as ordered by the physician. The dressing, dated 03/12/24, was not changed on 03/13/24 by the night shift nurse. Licensed nurses confirmed that the night shift nurse should have changed the dressing to prevent skin breakdown from leaking acidic stomach content. The facility lacked a policy to address changing dressings for gastrostomy insertion sites to prevent infections and maintain skin integrity. The facility failed to ensure that the resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and/or the residents' choices, related to skin treatments for this resident that required gastrostomy insertion site dressing changes.
Failure to Follow Physician Orders for Dressing Changes
Penalty
Summary
The facility failed to ensure that three residents received treatment and care in accordance with physician's orders related to skin treatments for ostomies. Resident 2, who had a suprapubic catheter, did not have his dressing changed as ordered by the physician. The dressing dated 03/12/24 was still in place on 03/14/24, despite orders to change it nightly. Licensed Nurse H confirmed that the dressing should have been changed on 03/13/24 and reported that the night shift nurse, who was an agency nurse, did not follow the physician's orders. This issue was not uncommon, and concerns had been previously reported but not adequately addressed by the administrative staff. Resident 3, who also had a suprapubic catheter, experienced a similar issue. The dressing dated 03/12/24 was not changed as ordered by the physician. Licensed Nurse H confirmed that the dressing should have been changed on 03/13/24 and reported that the night shift nurse did not follow the physician's orders. This issue was also reported to the previous administrative nurse but was not followed up on, and the most recent administrative nurse was not aware of the concern. Resident 4, who had a gastrostomy tube, did not have his dressing changed as ordered by the physician. The dressing dated 03/12/24 was still in place on 03/14/24, despite orders to change it nightly. Licensed Nurse H confirmed that the dressing should have been changed to prevent skin breakdown from leaking acidic stomach content. The facility lacked a policy to address following physician orders related to changing dressings for suprapubic catheter and gastrostomy tube insertion sites, leading to a failure in providing the necessary treatment and care for the residents.
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.
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