Galena Nursing & Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Galena, Kansas.
- Location
- 1220 E 8th Street, Galena, Kansas 66739
- CMS Provider Number
- 175233
- Inspections on file
- 17
- Latest survey
- March 30, 2026
- Citations (last 12 mo.)
- 3 (1 serious)
Citation history
Health deficiencies cited at Galena Nursing & Rehab Center during CMS and state inspections, most recent first.
A cognitively impaired, hemiplegic resident who depended on staff for ADLs developed significant bruising on the right leg and later vaginal bleeding and genital injuries while her son, acting as her representative, remained almost constantly in the room with the door closed and frequently participated in intimate care. Night-shift staff reported bruising and later bright red vaginal bleeding to an RN, who attributed the findings to the wheelchair, therapy, or scratching/yeast infection, instructed CNAs to apply antifungal cream without assessing the genital area, and did not notify administration or the provider. The next day, CNAs again observed dried blood and genital wounds, and an RN initially documented no skin issues before a later two-nurse assessment revealed extensive bruising to the hip, thighs, abdomen, and labia, with lacerations and shearing injuries, while the resident showed anxiety and made distressing statements. Staff had previously reported feeling uncomfortable with the son’s constant presence and controlling behavior during peri care, but these concerns were not acted upon, and the delay in recognizing and reporting injuries of unknown origin and in restricting the son’s access led surveyors to find that the resident was not protected from abuse and was placed in immediate jeopardy.
A resident with a DPOA frequently present during care developed significant bruising on the right leg and later bright red vaginal bleeding and labial injuries, which were repeatedly observed and reported by CNAs to RNs/LPNs over the course of a shift. Nursing staff accepted the DPOA’s explanations, attributed findings to therapy, wheelchair use, itching, or yeast infection, did not promptly assess or document all injuries, and failed to recognize them as potential physical and sexual abuse or injuries of unknown origin requiring immediate reporting. Despite additional observations of dried blood, vaginal lacerations, extensive bruising resembling a handprint, abdominal bruising, petechiae, and the resident’s anxious statements, administrative staff, LE, and the SA were not notified within required timeframes, and the resident remained alone in the room with the alleged perpetrator for many hours before suspected abuse was finally reported.
A cognitively impaired, functionally dependent resident with hemiplegia developed significant bruising on the right leg and later vaginal bleeding and genital bruising while a family representative (treated as DPOA) remained almost constantly in the room with the door closed. CNAs repeatedly reported bruising and vaginal bleeding to RNs/LNs, but the initial nurse accepted the representative’s explanation, did not thoroughly assess or document the injuries, and ordered antifungal treatment for presumed yeast infection without investigation. Oncoming nurses delayed assessment despite reports of bleeding, and when assessments were finally completed, staff found extensive bruising to the hip, thighs, lower abdomen, and labia, with lacerations and active vaginal bleeding, while staff statements described the representative as nervous, intrusive during intimate care, and always present. The resident made concerning statements implying harm by a male, yet no immediate protective measures were implemented, and the resident was left alone with the representative for many hours before the situation was reported as potential abuse.
Surveyors found that staff failed to provide necessary ADL care for several residents, including not shaving a resident with Alzheimer's, leaving a resident with dementia in soiled clothing, missing showers and personal hygiene for a resident with cognitive decline, and not assisting a resident with feeding despite documented need. Staff interviews and observations confirmed that these lapses were not due to resident refusal but rather inconsistent care and staffing issues.
A resident with end-stage renal disease who required dialysis did not have dialysis care needs addressed in the admission baseline care plan. The care plan and electronic medical record lacked documentation and orders for dialysis care, and staff did not perform required pre- or post-dialysis assessments or communicate with the dialysis center. Staff interviews revealed a lack of awareness and education regarding dialysis care requirements, resulting in the omission of essential care instructions.
A resident with chorea and Alzheimer's disease, who was sometimes dependent on staff for wheelchair mobility, did not have staff instructions in the care plan regarding the use of foot pedals during assisted wheelchair propulsion. Staff were observed propelling the resident without foot pedals, despite facility policy requiring comprehensive care plans with measurable objectives.
A resident with CHF experienced multiple significant weight gains that met the criteria for provider notification according to the care plan, but staff did not notify the provider as required. Nursing staff were aware of the notification protocol, and the resident was observed with edema and wearing compression socks. No supporting policy was provided.
A resident with chorea and Alzheimer's disease, who was generally independent but sometimes required staff assistance, was transported in a wheelchair without foot pedals in place. Staff propelled the resident while his feet were tucked under the seat and one foot was skimming the floor, contrary to facility expectations for safe transport. The facility lacked a policy on safe wheelchair transport.
The facility failed to maintain acceptable nutritional status for a resident by not providing required meal assistance, double portions, and nutritional shakes as outlined in the care plan, resulting in significant weight loss. Additionally, another resident with end-stage renal disease on dialysis did not have proper dietary assessment, care planning, or monitoring related to dialysis, and required weights and dietary orders were not consistently followed.
A resident with end-stage renal disease did not receive necessary dialysis assessments, care, or services. The care plan and medical record lacked documentation and orders for dialysis, and staff failed to perform required pre- and post-dialysis assessments, including vital signs, weights, and fistula checks. Staff interviews confirmed these omissions, and the facility did not coordinate with the dialysis center as required.
A resident with hypotension did not receive midodrine as ordered when their systolic blood pressure was below the specified threshold, and staff failed to notify the physician as required. Staff were also unaware of the medication order and proper monitoring procedures, and the resident was observed being assisted to lie down, contrary to care plan instructions.
Staff did not implement Enhanced Barrier Precautions (EBP), such as gowns and gloves, for several residents with Foley catheters, tube feedings, wounds, or ostomies. Observations showed a lack of EBP signage and PPE outside rooms, and interviews confirmed that staff were not using required protective equipment during care, despite facility policy mandating these precautions.
A resident with severe cognitive impairment and limited mobility was found to have a persistent six-inch gap between the mattress and head of the bed, due to the mattress being shorter than the bed frame. Facility staff confirmed the issue had existed for some time, and maintenance had not inspected the bed because it was provided by hospice. The facility did not ensure the bed and mattress were properly fitted or regularly inspected, as required by policy.
Failure to Protect Cognitively Impaired Resident From Suspected Sexual and Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively impaired resident from abuse and to respond appropriately to injuries of unknown origin, including bruising and vaginal bleeding. The resident had hemiplegia and severe cognitive impairment, required extensive assistance with ADLs, and depended on staff for care. Her care plan noted participation in activities but did not address the involvement of her son, identified as her representative and alleged perpetrator (AP), in her care, and listed another son as DPOA. Prior skin and weekly assessments documented no bruising or vaginal bleeding up to mid-March, and the last weekly skin assessment before the incident showed no bruises or open lesions. On the night in question, a CNA observed significant bruising on the resident’s right leg around late evening and reported it to the charge nurse (LN G). LN G assessed the bruising, determined it was probably from the wheelchair or therapy, and did not report it as an injury of unknown origin to administration. Later that night, around early morning, the same CNA observed bright red blood in the resident’s brief and vaginal area, along with what he thought might be clotted blood or a sore, and again reported this to LN G. LN G, relying on the AP’s report that the resident had been scratching and might have a yeast infection, instructed the CNA to apply antifungal powder or cream without personally assessing the vaginal area and without reporting the bleeding and possible injury to administration or the provider. During this time, the AP remained in the room with the resident, often with the door closed, and staff had previously reported feeling awkward and uncomfortable performing peri care while he was present. On the following day, a day-shift CNA providing peri care observed dried blood on the resident’s labia and vaginal area and notified another nurse (LN I), who noted dried blood and bruising on the right hip and leg and reported this to the charge nurse (LN H). Despite this, an earlier skilled evaluation by LN H that same day inaccurately documented no skin issues. Later that afternoon, a two-nurse assessment by LN H and LN I revealed a large bruise on the right hip and leg resembling the shape of a hand, extensive maroon/purple bruising and petechiae around and into the vagina, small lacerations and shearing injuries to the labia, and bruising on the lower abdomen and thighs. The resident displayed increased anxiety and repeatedly said “Oh God” during the assessment and was unable to explain how the injuries occurred. Multiple staff statements documented that the AP stayed in the room almost continuously with the door closed, remained present during intimate cares, acted nervous and fidgety, sometimes took over incontinent care, and left the building frantically after the injuries were discovered. The facility’s failure to recognize and report the initial bruising and vaginal bleeding as potential abuse, to promptly assess the resident, and to remove or restrict the AP allowed him to remain alone with the resident for many hours while her injuries progressed, resulting in a finding of immediate jeopardy. Additional documentation from the hospital and law enforcement supported concerns of sexual assault. The hospital record noted bleeding in the vaginal area with signs of injury, scattered bruises on the extremities, hips, and thighs, and documented that staff had concern for possible sexual assault. Hospital staff also recorded that the resident became agitated and yelled statements such as “Noooo why would a man do that” when her genitalia were cleaned, and that access to her hospital records was blocked from the patient portal due to reasonable belief that sharing them could result in harm to her life or physical safety. Witness statements from CNAs described the resident asking, “why she let that man do that” and saying “Son, why would you do this to me?” during care, though it was not documented that these statements were reported at the time. Law enforcement officers and the SANE examiner later described the resident’s wounds as among the worst they had seen and indicated that a warrant was required for the SANE exam because the AP, listed as legal representative, had left and could not be contacted. Throughout the period leading up to the discovery of the full extent of the injuries, staff had observed the AP’s constant presence, closed-door behavior, and controlling involvement in care, and some staff had reported discomfort and concerns to charge nurses, but these concerns were not acted upon prior to the incident. The facility’s abuse, neglect, and exploitation policy required prevention of all types of abuse and ensuring resident safety regarding visitors and representatives, but staff did not implement protective measures in response to the AP’s behavior or the resident’s injuries and statements. The failure to promptly recognize, assess, and report bruising and vaginal bleeding of unknown origin, combined with allowing the AP to remain alone with the resident with the door closed and to participate in intimate care despite staff discomfort and the resident’s cognitive impairment, led to the determination that the resident was not kept free from abuse and experienced preventable and intentional physical and sexual abuse and psychosocial trauma. The delay of approximately 16 hours from the initial report of bruising of unknown origin to notification of administrative staff, and the inaccurate documentation of no skin issues by LN H earlier on the day the injuries were identified, were key factors in the deficiency finding.
Removal Plan
- Re-education for abuse, neglect and exploitation (ANE) for all facility staff.
- Implemented a protection plan for Resident 1 (R1) requiring all cares be performed with two staff.
- Implemented a protection plan for R1 requiring the room door to remain open unless private cares were being provided.
- Implemented a protection plan for R1 requiring that if the alleged perpetrator (AP) entered the facility, law enforcement (LE) would be notified immediately.
- Implemented a protection plan for R1 requiring a staff member to go to R1's room and remain with her until law enforcement arrived if the alleged perpetrator entered the facility.
- Implemented a sign-in sheet for all visitors to the facility.
- Implemented a specific visitor log for R1.
Failure to Recognize and Timely Report Suspected Physical and Sexual Abuse
Penalty
Summary
The deficiency involves the facility’s failure to recognize and immediately report signs of possible physical and sexual abuse, including injuries of unknown origin and vaginal bleeding, for one resident. On the night of 03/21, two CNAs observed significant bruising on the resident’s right leg while providing care with the resident’s durable power of attorney (DPOA) and primary caregiver present. They reported the bruising to the charge nurse, who assessed the bruises as small, linear, and appearing old, accepted the DPOA’s explanation that they were from therapy or wheelchair positioning, and did not initiate an investigation, document the findings, or report the injury to administrative staff or external authorities. Later that night, at approximately 04:20 AM, the same CNA observed bright red vaginal bleeding and a possible lesion or clotted blood on the labia, reported this to the same nurse, and was instructed to clean the resident and apply antifungal cream for a presumed yeast infection without the nurse assessing the area or documenting the change in condition. At 06:00 AM, the night nurse verbally passed on that there had been vaginal bleeding, suspected to be from itching or a yeast infection, to the oncoming nurses and recommended contacting the provider, but no one identified these findings as potential abuse or an injury of unknown origin requiring immediate reporting. Around 08:00 AM, another CNA providing peri care with the DPOA present noted dried blood and small cuts or lacerations around the vaginal area and promptly notified a nurse, who confirmed dried blood, bruising on the hip, and a labial laceration but attributed the findings to itching and did not suspect abuse. This nurse reported the findings only to the resident’s charge nurse and did not notify administrative staff, law enforcement, or the state survey agency. During this period, multiple CNAs reported feeling uncomfortable and unsettled by the DPOA’s constant presence during intimate care, his refusal to leave the room, his habit of closing the door, and his jittery and anxious behavior, and at least two CNAs documented that the resident made distressing statements such as asking why they let “that man” do that and “Son, why would you do this to me?”, but these concerns were either not documented as reported or, when reported, were not acted upon. In the early afternoon, around 02:22 PM, two nurses jointly assessed the resident and identified extensive injuries, including a large bruise on the right hip and leg resembling the shape of a hand, dark maroon/purple bruising on the labia and into the vagina, a small laceration at the posterior vaginal opening, a shearing-type injury on the labia, scattered petechiae, bruising on the lower abdomen, and ongoing vaginal bleeding. The resident displayed increased anxiety during this assessment, repeatedly saying “Oh God,” and was unable to state what had happened. Only at this point did the nurses recognize the situation as potential sexual abuse and notify an administrative nurse, who then notified the administrator. Law enforcement was contacted later that afternoon, and the state survey agency was notified by email that evening, nearly 20 hours after the initial identification of an injury of unknown origin and several hours after administrative staff became aware of suspected abuse. Throughout the delay in recognition and reporting, the resident remained in the room with the alleged perpetrator, who had been present during all cares over the previous 23 hours and left the building frantically after the injuries were more fully recognized. The facility’s own abuse policy required immediate reporting, but not later than two hours after an allegation involving abuse or resulting in serious bodily injury, which was not followed in this case.
Failure to Protect Resident From Suspected Sexual Abuse and Investigate Injuries of Unknown Origin
Penalty
Summary
The deficiency involves the facility’s failure to implement protective measures and conduct timely assessment and investigation after injuries of unknown origin and signs of potential sexual abuse were identified for a cognitively impaired resident. The resident had hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side, severe cognitive impairment with a BIMS score of three, dependence on staff for nearly all ADLs, and no documented prior skin conditions. Her care plan did not address the alleged perpetrator’s (AP’s) involvement in care and listed another son as DPOA, while the AP was treated as the primary caregiver and remained in the room with the resident almost continuously, often with the door closed. Staff had previously felt awkward and uncomfortable performing care with the AP present and reported that he frequently remained in the room, watched cares closely, and sometimes took over intimate care, but these concerns were not acted upon. On the evening and night shift, CNAs observed significant bruising on the resident’s right leg and later vaginal bleeding, and reported these findings to the nurse. Around 10:30–11:00 PM, CNA staff reported significant bruising down the resident’s right leg to the nurse, who briefly assessed the bruises in the presence of the AP, accepted the AP’s explanation that the bruising might be from therapy or wheelchair positioning, and did not document the bruising in the EMR at that time. The resident was left alone in the room with the AP. Around 4:20 AM, CNA staff reported bright red blood in the resident’s brief and around the vaginal area to the same nurse, who did not assess the resident but instructed the CNA to apply antifungal cream or powder for a suspected yeast infection, again without further investigation or protective measures. The resident remained alone in the room with the AP with the door closed after care was completed. On the following day shift, multiple staff continued to identify concerning findings without immediate protective action. At approximately 6:00 AM, the night nurse told two oncoming nurses that the resident had vaginal bleeding suspected to be from itching or yeast infection, but no assessment was done at that time. Around 8:00 AM, a CNA providing peri care with the AP present observed dried blood all over the vaginal area and reported it to a nurse, who assessed the resident at about 8:30 AM, noted dried blood, bruising on the labia and vaginal opening, and bruising on the hip, but attributed the injuries to itching and did not suspect abuse; the resident was again left in the room with the AP. Later that afternoon, a two-nurse assessment revealed extensive bruising on the right hip and leg, bruising and lacerations to the labia and vaginal area, bruising on the lower abdomen, and active vaginal bleeding, with the bruising on the hip described as resembling the shape of a hand. During this assessment the AP left the room, which staff noted was unusual. Witness statements documented that throughout this period the AP remained in the room during cares, the door was mostly closed, staff felt unsettled and had previously reported discomfort with the AP’s presence, and the resident made statements such as “why I let that man do that?” and “Son, why would you do this to me?” during or after care. Despite these observations and escalating physical findings, the resident remained alone in the room with the AP for approximately 16 hours after the initial report of bruising and subsequent vaginal bleeding before the situation was reported to administrative staff as potential abuse. The EMR lacked timely documentation of the initial bruising and early vaginal bleeding, and a late entry note regarding the bruising was not entered until several days later, after surveyor interviews had begun. The facility’s abuse, neglect, and exploitation policy stated that the facility would ensure the health and safety of each resident regarding visitors such as family members or resident representatives, but staff did not remove or restrict the AP, did not initiate immediate protective measures when injuries of unknown origin and signs of possible sexual abuse were first identified, and did not promptly report or investigate the concerns. The deficiency was cited at a level of past noncompliance with actual harm, based on the existence of physical sexual abuse injuries that progressed while the resident was left alone with the AP and the likelihood of severe psychosocial trauma related to sexual abuse.
Failure to Provide Necessary ADL Care and Assistance
Penalty
Summary
Surveyors identified multiple failures by facility staff to provide necessary assistance with activities of daily living (ADLs) for several residents. One resident with Alzheimer's disease and chorea, who required substantial to maximum assistance for bathing and hygiene, was observed unshaven at breakfast. Staff interviews revealed that shaving was typically performed on shower days, but due to staffing shortages and the bath aide being reassigned to other duties, residents were not consistently receiving showers or being shaven as scheduled. Documentation showed missed or infrequent bathing opportunities, and staff confirmed the resident had not refused care. Another resident with severe cognitive impairment and dependent on staff for dressing was repeatedly observed in soiled clothing throughout the day, including at meals and while resting in bed. Despite multiple staff members interacting with the resident, her soiled clothing was not changed. Staff interviews confirmed the resident was fully dependent for dressing and that her clothing should have been changed if dirty, but this was not done. A third resident with a history of cerebral infarction and cognitive decline required substantial assistance with bathing and personal hygiene. This resident was observed unshaven with greasy, dirty hair, and records indicated missed or unattempted showers. Staff confirmed the resident had not refused care and that personal hygiene was not consistently provided. Additionally, another resident with moderate cognitive impairment and a history of stroke, who required substantial to maximum assistance with eating, was observed at meals without receiving needed feeding assistance until staff intervened later. Staff acknowledged the resident's increased need for help with eating, but assistance was not provided in a timely manner.
Failure to Address Dialysis Care Needs on Admission Baseline Care Plan
Penalty
Summary
The facility failed to address the immediate care needs of a resident with end-stage renal disease who was dependent on dialysis. Upon admission, the resident's baseline care plan did not include any documentation or instructions regarding dialysis care and services, despite the resident's medical record indicating a diagnosis of end-stage renal disease and a regular dialysis schedule. The electronic medical record also lacked orders related to dialysis care, and staff interviews confirmed that no pre- or post-dialysis assessments, vital signs, weights, or site assessments were performed by facility nurses. The resident reported that staff did not obtain vital signs, pre-dialysis weight, or assess the dialysis site prior to his departure for dialysis treatments. Further interviews with facility staff revealed a lack of awareness and education regarding the resident's dialysis care requirements. A certified nurse aide was only aware of a fluid restriction and not of other dialysis-related needs. A licensed nurse acknowledged that the facility missed necessary orders and assessments for dialysis care upon admission, and the administrative nurse confirmed that the baseline care plan should have included dialysis instructions. The facility's policy required baseline care plans to include instructions needed for effective and person-centered care, but this was not followed for the resident in question.
Failure to Include Foot Pedal Use in Resident's Care Plan
Penalty
Summary
The facility failed to complete a comprehensive care plan for one resident, specifically omitting staff instructions regarding the use of foot pedals when propelling the resident in his wheelchair. The resident had diagnoses of chorea and Alzheimer's disease, with a BIMS score indicating moderately impaired cognition. Documentation showed the resident was generally independent with his wheelchair and walker, but at times required staff assistance for mobility. The care plan noted the resident's jerking movements and independence with a walker but did not address the use of foot pedals during staff-assisted wheelchair propulsion. Observations revealed that staff propelled the resident in his wheelchair without foot pedals, with the resident's feet crossed and tucked under the seat, and the toe of his left foot skimming the floor. Staff interviews confirmed that while the resident usually propelled himself, he sometimes needed staff assistance, at which point foot pedals were expected to be used. The facility's policy required comprehensive, person-centered care plans with measurable objectives and timeframes, but the care plan lacked specific instructions for staff regarding foot pedal use during assisted wheelchair mobility.
Failure to Notify Provider of Significant Weight Gains in Resident with CHF
Penalty
Summary
A deficiency occurred when the facility failed to monitor and report significant weight fluctuations for a resident with a diagnosis of congestive heart failure (CHF). The resident's care plan required daily weights and provider notification for weight gains of three pounds overnight or five pounds in three days, as well as for increased shortness of breath or swelling. Despite this, the electronic medical record showed multiple instances where the resident experienced weight gains meeting or exceeding these thresholds, but there was no documentation that the provider was notified as required by the care plan. Observations confirmed the resident had edema in both legs and was wearing compression socks. Interviews with nursing staff revealed awareness of the notification requirement, and administrative staff stated the expectation that orders be followed. However, no policy was provided to support the process, and the required notifications to the provider were not made on several occasions when the resident's weight increased significantly.
Failure to Use Wheelchair Foot Pedals During Staff-Assisted Transport
Penalty
Summary
Staff failed to ensure a safe environment free from accident hazards for a resident diagnosed with chorea and Alzheimer's disease. The resident, who had moderately impaired cognition and was generally independent with mobility, was observed being propelled in a wheelchair by staff without foot pedals in place. During this incident, the resident's feet were crossed and tucked under the seat, with one foot skimming the floor, increasing the risk of injury. The staff member stated that foot pedals were not used because the resident usually propelled himself, but at times, staff assistance was required for mobility. Further interviews confirmed that staff were expected to use foot pedals when propelling the resident in the wheelchair. The facility did not provide a policy regarding the safe transport of residents in wheelchairs. The lack of foot pedals during staff-assisted wheelchair propulsion constituted a failure to maintain a safe environment and prevent avoidable accidents for the resident.
Failure to Maintain Nutritional Status and Properly Assess Dialysis-Related Needs
Penalty
Summary
The facility failed to provide adequate care and services to maintain acceptable nutritional status for two residents. For one resident with a history of stroke, diabetes, and cognitive impairment, the care plan required substantial to maximal assistance with eating, a soft diet with double portions, and nutritional shakes. Despite these interventions, the resident experienced significant weight loss over a two-month period. Observations revealed that staff did not consistently provide the required assistance during meals, and the resident was often left unattended with food and nutritional shakes, resulting in incomplete consumption. Additionally, the kitchen was not informed of the double portion requirement, so the resident did not receive the prescribed diet enhancements. Documentation in the electronic medical record for this resident did not reflect the observed weight loss, and there was a lack of communication and follow-through regarding dietary interventions. Staff interviews confirmed that the resident's need for assistance with eating had increased, but this was not consistently addressed during meal times. The facility also lacked a restorative aide, and nurse aides were expected to provide the necessary support, which was not reliably done. For another resident with end-stage renal disease on dialysis, the facility failed to properly assess and document nutritional needs related to dialysis. The baseline care plan did not include any information about dialysis care, dietary restrictions, or fluid management, despite hospital discharge instructions specifying a diabetic, heart-healthy diet. Orders for daily and weekly weights were not consistently followed, and the registered dietitian's assessment did not address the resident's dialysis status. Staff interviews confirmed that essential dialysis-related care and monitoring were missed, and the care plan was incomplete regarding the resident's specialized needs.
Failure to Provide Required Dialysis Assessment and Care
Penalty
Summary
The facility failed to provide necessary dialysis assessment, care, and services for a resident diagnosed with end-stage renal disease who was dependent on dialysis. The resident's baseline care plan did not include documentation of dialysis services or instructions for dialysis care. The electronic medical record lacked orders related to dialysis care, and there was no evidence of completed dialysis communication forms before or after treatments. Progress notes inconsistently documented the resident's dialysis schedule and did not consistently record whether the resident attended dialysis, returned from dialysis, or received assessments related to dialysis. On several occasions, there was no documentation of pre- or post-dialysis assessments, vital signs, weights, or fistula assessments. Interviews with staff revealed that the facility missed entering dialysis orders and did not perform required pre- and post-dialysis assessments. The resident reported that nurses did not obtain vital signs, pre-dialysis weight, or assess the dialysis site before he left for dialysis, and sometimes he left before breakfast. Staff confirmed that the resident's representative transported him to dialysis, which contributed to the missed assessments. The facility's hemodialysis policy required coordination and collaboration with the dialysis center to meet the resident's needs, but this was not followed in practice.
Failure to Monitor and Administer Midodrine per Physician Orders
Penalty
Summary
Staff failed to ensure proper blood pressure monitoring and administration of midodrine for a resident diagnosed with hypotension. The resident's care plan and physician's order required staff to check blood pressure before administering midodrine, only give the medication if the systolic blood pressure (SBP) was less than 100 mm/Hg, and ensure the resident was sitting upright during administration. The care plan also instructed staff not to give the medication while the resident was lying down or within four hours of bedtime. Record review showed that on two occasions, the resident's SBP was below 100 mm/Hg, but midodrine was not administered and the physician was not notified as required. Additionally, staff interviews revealed a lack of awareness of the medication order and the need to notify the provider for out-of-range blood pressures. Observations also indicated that the resident was assisted to lie down after eating, which could conflict with the care plan instructions regarding medication administration.
Failure to Implement Enhanced Barrier Precautions for Residents with Indwelling Devices and Wounds
Penalty
Summary
Facility staff failed to implement Enhanced Barrier Precautions (EBP), including the use of gowns and gloves, for residents with conditions requiring such measures. Specifically, one resident with a Foley catheter, another receiving tube feedings and wound care, and a third with an ostomy did not have EBP signage or personal protective equipment (PPE) available or in use. Observations revealed that no EBP signage or PPE was present outside any of the residents' rooms, and staff did not use gowns or gloves when providing care to these residents. Interviews with the affected residents confirmed that staff did not use appropriate protective equipment during care activities. Staff interviews indicated a lack of consistent EBP implementation, with some staff acknowledging that EBP should be used for residents with indwelling devices or wounds, but admitting that these precautions had not been followed. The facility's policy required EBP for residents with wounds or indwelling medical devices, and mandated that gowns and gloves be made available near or outside the resident's room. Despite this, staff reported that EBP had not been practiced, and attributed the lapse to staff oversight and recent changes in nursing leadership.
Failure to Inspect and Maintain Safe Bed Equipment
Penalty
Summary
A deficiency was identified when the facility failed to regularly inspect a resident's bed frame and mattress as part of its maintenance program, specifically to identify areas of possible entrapment. The resident involved had a diagnosis of dementia with severe cognitive impairment, as indicated by low BIMS scores, and was dependent on staff for bed mobility. Observations revealed a persistent gap of approximately six inches between the top of the mattress and the head of the bed. Staff interviews confirmed that the mattress had been shorter than the bed frame for an extended period, and maintenance staff had not checked the bed because it was supplied by hospice and not considered a facility bed. The resident's care plan noted that hospice would provide the bed and mattress, but there was no evidence that the facility ensured the equipment was safe or properly fitted. The facility's policy required reasonable accommodations to individualize the resident's environment, including the bedroom, but this was not followed in this case. The lack of inspection and failure to address the mismatch between the mattress and bed frame placed the resident at risk for injury.
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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