Spring View Manor Healthcare And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Conway Springs, Kansas.
- Location
- 412 S 8th Street, Conway Springs, Kansas 67031
- CMS Provider Number
- 175504
- Inspections on file
- 14
- Latest survey
- March 17, 2026
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at Spring View Manor Healthcare And Rehabilitation during CMS and state inspections, most recent first.
Surveyors found multiple sanitation issues in the kitchen, including improperly stored frozen and refrigerated foods such as open bags of food with ice crystals, an unsealed bag of meat, and an opened package of cheese. Dietary staff were observed delivering meals while placing their thumbs on the eating surfaces of plates. Dishwasher temperatures were measured below the level a staff member stated was needed for proper disinfection, and prior service reports showed low wash and final rinse temperatures. A staff member reported that the water heater pilot light went out at times and that staff were expected to monitor temperatures, while the written dishwashing policy lacked specific temperature requirements for cleaning and sanitizing dishware and cookware.
The facility did not ensure that all CNAs received the required minimum of 12 hours of annual in-service training, including topics such as dementia care and abuse prevention. Review of records for several CNAs employed more than one year showed that two CNAs had only seven and eight documented training hours over the prior year. An administrative nurse confirmed the 12-hour annual requirement and the absence of additional training records for these CNAs, and the facility was unable to provide a policy outlining its CNA in-service training program.
The facility failed to issue required CMS-10055 SNF Advanced Beneficiary Notices of Non-Coverage (ABN), including estimated costs, to two Medicare Part A beneficiaries when their skilled coverage ended and they remained for custodial care. Review of electronic medical records showed that both residents had defined Medicare Part A episodes followed by continued custodial stays, but there was no documentation that ABNs were provided. The facility’s own Advance Beneficiary Notice policy required timely notification of Medicare eligibility, coverage, and potential liability for payment before providing items or services that may not be covered, such as custodial care. An interview with social services staff revealed unawareness of the need to complete and issue the ABN, and the facility could not produce evidence that the CMS-10055 form was given to either resident.
A resident with obesity, O2 dependence, cognitive communication deficit, and skin cancer experienced respiratory symptoms and was transferred to the hospital after nursing staff documented shortness of breath, productive cough, and low O2 saturation, with a phone message left for the responsible party. Although the EMR showed a bed-hold assessment with verbal confirmation and the resident later returned for skilled therapy, there was no written notice explaining the reason for transfer provided to the resident or representative, nor was a copy sent to the ombudsman. Interviews with the resident, social services, and an administrative nurse revealed that staff were unaware or unsure of written notification requirements and that the facility had not been consistently issuing written transfer notices or ombudsman notifications, contrary to its own transfer/discharge policy requiring detailed written notice and appeal information.
Surveyors found that dietary staff did not follow the approved recipe for pureed green beans, using tap water instead of an appropriate hot liquid, which altered the food’s nutritive content. Staff also failed to consistently monitor and maintain required food temperatures, with pureed spaghetti and cooked spaghetti served below the facility’s 135°F hot holding standard and an Italian tossed salad served above the 41°F cold holding standard. A resident reported that tray-delivered meals were only “kind of warm,” and a dietary staff member acknowledged that they do not routinely take temperatures of cooked or pureed foods before service, despite facility policy requiring specific hot and cold holding temperatures.
Surveyors identified multiple infection control failures, including staff entering a resident’s room on EBP wearing gloves without prior hand hygiene and continuing incontinence care while wearing soiled gloves, then changing gloves without hand hygiene. Two residents’ nebulizer masks and equipment were found lying directly on bedside tables, one with residual fluid, and not stored in sanitary containers between treatments. An RN performed an enteral dressing change without a gown, used gloves taken from a pants pocket, and placed a new syringe plunger into a soiled container. The same RN performed wound care for another resident while repeatedly leaving and re-entering the room, assisting the roommate, kneeling on the floor, handling dressings, and completing the wound care without changing gloves or performing hand hygiene, despite facility policies requiring proper hand hygiene, glove changes between soiled and clean tasks, appropriate PPE, and sanitary storage of nebulizer equipment.
A resident’s EMR lacked required documentation showing that an influenza (flu) vaccine was offered, accepted, declined, or contraindicated, despite the facility’s policy to offer annual flu immunizations. During review, there was no record in the immunization section of the EMR of a flu vaccine, a documented offer, a legal representative’s informed declination, or a physician-documented contraindication. The IP, who tracks immunizations, reported having contacted the resident’s legal representative and stated the vaccine was declined, but this was not documented in the EMR in accordance with facility policy.
The facility did not ensure that daily nurse staffing sheets accurately reflected actual hours worked by RNs, LPNs, and CNAs. On the day reviewed, the posted staffing form, observed twice near the nurse’s station with a census of 40 residents, lacked actual hours worked per shift for licensed and unlicensed staff providing resident care. An LN and administrative nurses reported that nurses did not update the posted sheet when staff were late or absent and that the business office added actual hours at the end of the week, contrary to facility policy requiring real-time updates after each shift.
The facility did not conduct required annual evaluations for four CNAs and CMAs employed for over a year. Personnel files lacked documentation of these evaluations, contrary to the facility's policy. This was confirmed through a review and an interview with a consultant.
The facility failed to submit accurate direct care staffing information to CMS for the second and fourth quarters of 2023. The Payroll Base Journal (PBJ) submissions did not include agency staff used on weekends, leading to reports of excessively low weekend staffing. The facility lacked a policy for PBJ submission, contributing to the inaccurate reporting.
The facility failed to provide adequate education for informed decision-making regarding influenza, pneumococcal, and COVID-19 vaccinations for several residents. Medical records lacked documentation of education or evidence of vaccine receipt or declination, contrary to facility policies. Interviews confirmed the absence of proper documentation, leading to deficiencies in vaccine administration.
A resident with severe cognitive impairment and physical limitations did not receive adequate grooming, as staff failed to shave him regularly despite his discomfort with facial hair. The resident, who required assistance with ADLs, was observed with several days' worth of facial hair growth. Staff were unaware of his last shower, and the facility's grooming policy was not followed, affecting the resident's well-being.
The facility failed to follow physician orders and provide timely lab reporting for two residents. One resident did not have labs obtained promptly, delaying treatment for nausea and vomiting. Another resident did not receive medications as prescribed for weight gain and hypertension, with staff administering Lisinopril despite low blood pressure readings. The facility lacked a policy for following physician orders.
A facility failed to follow infection control practices during medication and insulin administration for two residents. A nurse did not sanitize a gastrostomy tube or syringe before administering medications to a resident with a swallowing disorder. Additionally, the same nurse did not perform hand hygiene between administering insulin to two residents, contrary to facility policy.
The facility did not ensure daily staff postings included actual hours worked, as required. A review of postings from February to April 2024 showed missing hours, confirmed by an interview with an administrative staff member. The business office recorded hours via a computer program, and the facility lacked a policy for daily staff posting.
Unsanitary Food Storage, Handling, and Dishwashing Practices
Penalty
Summary
Surveyors identified deficiencies in the facility’s food storage and preparation practices. During an initial kitchen tour with dietary staff, three open plastic bags of food were observed in the freezer with ice crystals formed directly on the food items, along with one unsealed bag of meat and one opened package of cheese. These items were not properly sealed, indicating improper storage of frozen and refrigerated foods. Additional observations showed dietary staff handling resident meal plates by placing their thumbs on the eating surfaces of the plates while delivering meals to residents. Surveyors also found deficiencies in dishwashing and sanitization practices. A dietary staff member measured the dishwasher water temperature at 103°F, and stated that the water temperature should be 120°F to properly disinfect and sanitize dishware and cookware. Review of recent kitchen service reports showed that both the wash and final rinse temperatures of the dishwasher had been recorded at 122–123°F on prior dates. Another staff member reported that the pilot light on the water heater went out at times and that staff were expected to monitor dishwasher temperatures and not run dishes if the temperature was below 120°F. The facility’s written dishwashing policy from 2020 did not specify required temperatures for cleaning, disinfecting, or sanitizing dishware and cookware.
Failure to Ensure Required Annual In-Service Training for CNAs
Penalty
Summary
The facility failed to develop, implement, and permanently maintain an in-service training program for CNAs that ensured at least 12 hours of annual education with required topics such as dementia care and abuse prevention. During a survey with a reported census of 40 residents, review of training records for five CNAs employed more than one year showed that two CNAs had less than 12 hours of documented in-service training in the previous 12 months. One CNA, employed since 12/20/23, had eight hours of documented training, and another CNA, employed since 07/22/24, had seven hours of documented training. The Administrative Nurse confirmed that all CNAs were required to have 12 hours of training annually and acknowledged there were no additional training records for these CNAs, and the facility did not provide a policy governing the in-service training program. These findings demonstrate that the facility did not ensure all CNAs received and had documentation of the minimum required annual in-service training hours, nor did it provide evidence of a formal policy to support and maintain the required training program.
Failure to Issue Required ABNs When Medicare Part A Coverage Ended
Penalty
Summary
The facility failed to provide required CMS-10055 Skilled Nursing Facility (SNF) Advanced Beneficiary Notices of Non-Coverage (ABN), including estimated costs for continued services, to two Medicare Part A beneficiaries when their skilled coverage ended and they remained for custodial care. Record review showed that one resident had a Medicare Part A episode from 09/18/25 to 10/20/25 and then remained in the facility for custodial care, but the electronic medical record contained no evidence that an ABN was issued. Another resident had a Medicare Part A episode from 10/25/25 to 12/24/25 and also remained for custodial care, with no documentation in the electronic medical record that an ABN was provided. The facility’s policy on Advance Beneficiary Notices, reviewed 05/07/25, required timely notices regarding Medicare eligibility and coverage and informing beneficiaries of potential liability for payment, including issuing a liability notice upon admission or during the stay before providing items or services that may not be covered because they are not medically reasonable and necessary or are custodial care. Interviews confirmed that the responsible social services staff member was not aware of the requirement to complete and issue the ABN, and the facility was unable to produce evidence that the CMS-10055 form was given to either resident.
Failure to Provide Required Written Transfer and Bed-Hold Notifications
Penalty
Summary
Surveyors identified a failure to provide required written notification of transfer for a resident who was hospitalized. The resident had diagnoses including obesity, dependence on supplemental oxygen, cognitive communication deficit, and skin cancer. On 12/11/25, nursing notes documented the resident was short of breath, coughing up yellow sputum, and had an oxygen saturation of 88%, leading to new medication, lab orders, and a mobile chest X-ray. Later that day, a nurse documented leaving a message for the responsible party that the resident was going to the hospital, and that the resident left with emergency services. The resident returned to the facility on 12/22/25 and was to receive skilled therapy services. The EMR contained a bed-hold assessment with verbal confirmation but lacked documentation of written notification to the resident and/or representative explaining the reason for the transfer to the hospital. During interviews, the resident stated he was supposed to sign the bed hold but was not given it before leaving for the hospital. Social Service staff reported that one social worker obtained bed holds when a resident left, but they were not aware of or unsure about sending written letters to residents or representatives or notifying the ombudsman. Administrative nursing staff confirmed the facility had not been sending written notifications to families with the reason for transfer, nor sending notifications to the ombudsman, noting that an email had been sent one month prior but not since. This practice was inconsistent with the facility’s Transfer and Discharge policy, which requires that a transfer/discharge notice be provided to the resident and representative, including the specific reason for transfer, effective date, destination, appeal rights and procedures, and contact information for the state appeal entity, ombudsman, and protection and advocacy agencies where applicable.
Failure to Follow Puree Recipe and Maintain Safe Food Temperatures
Penalty
Summary
Surveyors identified a deficiency related to food preparation and service temperatures. During observation of meal preparation, a dietary staff member added tap water to green beans while pureeing them, despite the facility’s recipe specifying that, if thinning was needed, staff should gradually add an appropriate hot liquid such as broth, gravy, milk, or reserved cooking liquid. This deviation from the recipe altered the nutritive content of the pureed green beans. The facility’s written recipe and procedures did not authorize the use of tap water for this purpose. Additional observations showed that staff did not consistently ensure hot and cold foods were served at safe and appetizing temperatures. Pureed spaghetti delivered to the dining room was measured at 127°F, and a plated hall tray of cooked spaghetti delivered to a resident’s room was measured at 130°F, both below the facility’s required hot holding/serving temperature of 135°F or higher. The Italian tossed salad on the same tray was measured at 52°F, above the required cold holding/serving temperature of 41°F or below. A resident reported that food served to their room was not hot but “kind of warm.” One dietary staff member stated they do not obtain temperatures on cooked food or cooked pureed food before sending it to the dining room, while another dietary staff member acknowledged the facility’s expectations that hot foods be maintained at 135°F or above and cold foods at 41°F or below, as outlined in the facility’s 2020 Monitoring Food Temperatures for Meal Service policy.
Failure to Follow Hand Hygiene, PPE, and Nebulizer Storage Practices Under EBP
Penalty
Summary
The deficiency involves failures in infection prevention and control practices, including improper hand hygiene, PPE use, and storage of nebulizer equipment. Surveyors observed that two staff members entered a resident’s room on Enhanced Barrier Precautions (EBP) wearing gloves but without performing hand hygiene. During incontinence care, one staff member continued to pull up the resident’s pants while still wearing soiled gloves, then removed and reapplied gloves without hand hygiene. In separate observations, two residents’ nebulizer masks and equipment were found lying directly on bedside tables, one with residual fluid in the chamber, and not stored in sanitary containers between treatments, contrary to facility expectations. Additional observations showed a nurse performing dressing changes without adhering to EBP and infection control standards. For one resident with an enteral feeding site, the nurse used gloves taken from his pants pocket, did not don a gown for the dressing change, and placed a new syringe plunger into a soiled container without cleaning it. For another resident receiving wound care, the same nurse donned gloves from his pocket and a gown, left and re-entered the room multiple times without changing gloves or performing hand hygiene, assisted the roommate while wearing the same gloves, knelt on the floor, handled dressing supplies, cleansed and dressed the wound, and used a marker from his pocket to date the dressing, all without changing contaminated gloves. Facility leadership and the Infection Preventionist later confirmed that nebulizers should be bagged between treatments, PPE (including gowns) should be worn for dressing changes, gloves should be changed between soiled and clean tasks, and hand hygiene should be performed between glove changes, as required by the facility’s hand hygiene and EBP policies.
Failure to Document Influenza Vaccination Offer and Declination
Penalty
Summary
The deficiency involves the facility’s failure to follow its influenza vaccination policy by not properly documenting the offer, consent, declination, or contraindication for an influenza vaccine for Resident 28. The facility had a census of 40 residents, with a sample of 12 residents and 5 reviewed for immunization status. Record review of Resident 28’s EMR under the Immunization tab showed no documentation that the influenza vaccine was offered or declined, and no record of a historical influenza vaccination or a physician-documented contraindication, despite the resident’s admission earlier in the month. Although the facility later provided a declination form for the annual influenza vaccination dated the day after the record review, this documentation was not present at the time of the initial review. During an interview, the Infection Preventionist, who was responsible for tracking immunizations, stated she had left a message with the resident’s legal representative regarding immunizations and reported that the legal representative had declined the influenza vaccination, but this declination was not documented in the EMR as required by facility policy. The facility’s written Influenza Vaccination policy stated that it was the policy of the facility to minimize the risk of acquiring, transmitting, or experiencing complications from influenza by offering annual influenza immunization to residents, staff, and volunteers, but the required documentation of this process was not completed for Resident 28.
Failure to Post Accurate Daily Nurse Staffing Hours
Penalty
Summary
The facility failed to ensure that the posted daily nurse staffing sheets contained accurate and identifiable information, specifically the actual hours worked per shift by licensed and unlicensed staff providing resident care. On the survey date, the posted nurse staffing form for that day, observed near the nurse’s station, did not include the actual hours worked for RNs, LPNs/LVNs, and CNAs. The form was observed twice on the same day and on both occasions lacked the required actual hours worked per shift. The facility census at the time was 40 residents. Staff interviews confirmed that actual hours were not being updated on the posted staffing sheets as required by facility policy. An LN reported that nurses do not change the time or add actual hours on the posted sheet, even when staff arrive late, and that the business office updates the information later. An administrative nurse stated she placed the staffing sheet out and that the office added actual hours at the end of the week, with no adjustments made before then. Another administrative nurse stated that nurses should be entering the actual hours on the posted staffing sheet after the start of each shift. This practice conflicted with the facility’s written Nurse Staffing Posting Information policy, which required daily posting of staffing sheets with actual hours worked and updates after the start of each shift to reflect staff absences and call-outs.
Failure to Conduct Annual Evaluations for CNAs and CMAs
Penalty
Summary
The facility failed to ensure that four out of five Certified Nurse Aides (CNA) and Certified Medication Aides (CMA/CNA) who were employed for over a year received their required annual evaluations. The personnel files of these staff members, specifically CNA N, CNA M, CNA O, and CMA R, lacked documentation of annual evaluations. This deficiency was identified during a review of personnel files and confirmed through an interview with consultant GG, who stated that she expected staff to have evaluations annually. The facility's policy, implemented in December 2019, mandates a formal written evaluation of employees' work performance annually, which was not adhered to in these cases.
Inaccurate PBJ Submission for Weekend Staffing
Penalty
Summary
The facility failed to electronically submit complete and accurate direct care staffing information to the Centers for Medicare and Medicaid Services (CMS) for the second and fourth quarters of 2023. Specifically, the facility did not accurately report weekend staffing, as the Payroll Base Journal (PBJ) submissions did not include agency staff used to supplement the nursing staff employed by the facility. This resulted in the PBJ triggering for excessively low weekend staffing for both quarters. The facility lacked a policy for PBJ submission, which contributed to the inaccurate reporting of hours. An interview with Administrative Staff A revealed that the corporate office was responsible for submitting the PBJ, and the omission of agency staff led to the deficiency.
Deficiency in Vaccine Education and Documentation
Penalty
Summary
The facility failed to ensure that residents received proper education for informed decision-making regarding vaccinations, leading to deficiencies in the administration of influenza, pneumococcal, and COVID-19 vaccines. Specifically, two residents, R21 and R11, did not receive education for the 2023 influenza vaccine, and R21 also lacked education for the pneumococcal vaccine. Additionally, three residents, including R21 and R3, did not receive education for informed decision-making regarding the COVID-19 vaccine. The medical records for these residents lacked documentation of education provided for informed decision-making or evidence of receipt or declination of the vaccines. The facility's policies on influenza, pneumococcal, and COVID-19 vaccinations, implemented in 2019 and 2022, instructed staff to offer and educate residents about these vaccines. However, interviews with the administrative nurse confirmed the absence of documented declinations or undated declinations for the residents involved. This lack of documentation and education resulted in the facility's failure to provide residents with the opportunity to make informed decisions about their vaccinations, as required by the facility's policies.
Failure to Provide Adequate Grooming for Resident
Penalty
Summary
The facility failed to provide adequate personal grooming for a resident with severe cognitive impairment and physical limitations. The resident, who had a history of hemiplegia, hemiparesis, cerebral vascular accident, and major depressive disorder, was assessed as requiring staff assistance with activities of daily living, including personal hygiene. Despite the care plan indicating the resident was dependent on staff for bathing and personal hygiene, observations revealed the resident had several days' worth of facial hair growth, which he did not desire and found uncomfortable. Interviews with staff indicated that the resident was typically shaved on shower days, but there was a lack of awareness regarding the resident's last shower. The resident had refused showers on several occasions during the evening shift, and staff confirmed he needed a shave. The facility's policy on grooming facial hair instructed staff to assist residents in maintaining proper hygiene, yet the resident did not receive grooming opportunities according to his preferences, impacting his sense of well-being.
Failure to Follow Physician Orders and Timely Lab Reporting
Penalty
Summary
The facility failed to provide timely pharmaceutical services for two residents, leading to deficiencies in care. For one resident with chronic respiratory and heart failure, diabetes, and kidney failure, the facility did not obtain laboratory values in a timely manner. Despite the physician's instructions to obtain a Complete Blood Count (CBC) and Comprehensive Metabolic Panel (CMP) due to the resident's ongoing nausea and vomiting, the facility delayed obtaining these labs by two days. This delay was attributed to the laboratory's failure to provide a phlebotomist promptly. Additionally, the facility did not report the laboratory results to the physician on the day they were obtained, further delaying necessary medical intervention. Another resident with hypertension, heart failure, and chronic kidney disease did not receive medications as per physician orders. The facility failed to administer Bumex for weight gain as instructed, despite documented weight increases that met the criteria for administration. Furthermore, the facility administered Lisinopril for hypertension even when the resident's blood pressure readings were below the parameters set by the physician. These failures were compounded by the absence of a facility policy for following physician orders, leading to non-compliance with prescribed medical care.
Infection Control Lapses in Medication and Insulin Administration
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices during the administration of medications and insulin for two residents. For Resident 1, who had a history of cerebral vascular accident and a swallowing disorder, a Licensed Nurse (LN) was observed administering medications through a percutaneous gastrostomy tube without cleaning or sanitizing the tube or syringe. The syringe was placed directly on a paper towel on the resident's bedside table, which did not adhere to the facility's policy requiring infection control precautions to minimize contamination risk. In another instance, a Licensed Nurse was observed administering insulin to a resident with diabetes without performing hand hygiene between residents. The nurse picked up an insulin pen and prepared to administer insulin without sanitizing her hands, although she later verified the need to do so. This action was contrary to the facility's policy, which required hand hygiene and glove use before and after insulin administration. These lapses in infection control practices could potentially lead to the spread of infections among residents.
Failure to Record Actual Staff Hours on Daily Postings
Penalty
Summary
The facility failed to ensure that the daily staff postings included the actual hours worked by staff, as required. During a review of the daily staff postings from February, March, and April 2024, it was found that the postings lacked the actual hours worked for staff members. An interview with Administrative Staff A confirmed that the facility did not record the actual hours worked on the daily staff posting sheets. Instead, the business office documented these hours through a computer program. Additionally, the facility did not have a policy in place for daily staff posting, contributing to the deficiency.
Latest citations in Kansas
Surveyors identified unsanitary food storage and preparation conditions, including food debris in a reach-in freezer, an unknown spilled liquid in a reach-in refrigerator, missing two-inch air gap on an ice machine drain, dirty carts used for clean dishes, and a steamtable shelf with built-up food debris. A dietary staff member acknowledged these areas needed cleaning, and it was determined the facility lacked a cleaning schedule or policy for kitchen cleanliness.
The facility failed to complete and analyze Care Area Assessments (CAAs) for multiple residents after Admission, Annual, and Significant Change MDS assessments triggered areas such as cognition, mood/behavior, functional status, urinary incontinence/indwelling catheter, nutrition, dental care, pressure ulcers, pain, falls, psychotropic drug use, psychosocial well-being, and visual function. Instead of documenting individualized analysis of underlying causes and contributing factors, an LPN reported she had stopped writing CAA notes and relied mainly on check-off worksheets and the fact that triggers appeared in the MDS CAA section. No facility policy on CAAs was provided to surveyors, and the CAAs consistently lacked required analytical documentation for residents with diverse and significant clinical needs.
A resident with dementia, severe cognitive impairment, and an indwelling urinary catheter was repeatedly observed sitting in common areas with his catheter drainage bag resting on his lower leg, visibly filled with dark amber urine and lacking a privacy cover, despite a care plan directing staff to cover the drainage bag. CNAs reported that the bag often slid down from the resident’s thigh, that they did not use catheter dignity bags on their hall, and that they simply moved the bag back up when it slid down. An administrative nurse stated she had not considered the use of dignity bags on the memory care unit, even though the facility’s resident rights policy affirms each resident’s right to a dignified existence, privacy, and confidentiality.
Two residents with documented cognitive ability to participate in care planning were not invited to any care plan meetings, and their EMRs lacked evidence of care plan conferences, invitations, or Interdisciplinary Care Conference assessments. Administrative staff stated that invitations should be mailed or hand-delivered and uploaded to the EMR, and that an Interdisciplinary Care Conference note should be completed, but none of this documentation existed for these residents, contrary to facility policy and federal requirements for resident and/or representative participation in care planning.
A resident with C-diff and CHF, newly admitted and with a baseline care plan that did not address call light use, was repeatedly found without access to a call light. Surveyors observed the resident yelling for help with her room door closed and later noted the call light on the floor under the bed and again on the floor while the resident sat in a recliner and stated she wanted to return to bed but could not do so independently. Staff reported using a binder clip to attach the call light to the resident’s clothing because the cord lacked a clip, acknowledged the resident sometimes threw the call light to the floor, and stated that call lights should be kept within residents’ reach. An administrative nurse confirmed the expectation that call lights be accessible at all times and was unsure about the use of a binder clip, and no facility policy on call lights was provided.
Surveyors found that a resident’s bathroom and handwashing area were not maintained in a safe, sanitary, and comfortable condition, including a loose baseboard with black substance behind it, a cracked toilet seat, and an empty, improperly mounted hand soap dispenser. Maintenance staff confirmed these conditions, noted that the soap dispenser was nonfunctional, and reported that although a QR code system existed for reporting maintenance issues, these problems had not been reported. Maintenance staff also stated there were no facility policies for maintenance repair in resident rooms and no policy provided for ensuring a safe, homelike environment.
Multiple residents were affected by inaccurate MDS assessments, including a resident with dementia and an indwelling catheter who was miscoded as always incontinent of urine and independent in ADLs despite staff and EMR documentation showing long-term catheter use and total dependence for dressing and wheelchair positioning. Another resident with a history of stroke was incorrectly coded as having a restraint, even though bed grab bars were used as enablers to assist with repositioning and did not limit voluntary movement. A resident with diabetes and unsteadiness experienced two documented falls that were not captured on the MDS, and another resident with diabetes, depression, CAD, and CKD was actively receiving hospice services per EMR, social services, and staff interviews, yet hospice was not coded on the MDS. The consultant MDS nurse confirmed these were significant coding errors not in accordance with the RAI User’s Manual.
A resident with C. diff and CHF was admitted, and while a baseline care plan documenting contact precautions was created, the resident later reported not knowing what a baseline care plan was. The resident was also found yelling for help with her call light on the floor under the bed. Nursing staff stated that baseline care plans are started on the day of admission and reviewed with residents, but also indicated that residents and families are not given written copies. An administrative nurse claimed a 48-hour interdisciplinary care conference had been completed, yet no corresponding documentation existed in the EMR, and explanations about who was responsible and why it was missing were inconsistent. No facility policy for baseline care plans was provided.
A resident with dementia and severe cognitive impairment was inaccurately assessed and care planned as needing only setup or independent assistance with dressing, despite actually requiring total staff assistance. The EMR lacked clear ADL documentation, and the ADL CAA did not trigger, leading to inaccurate MDS entries and a care plan that did not match the resident’s functional status. Surveyors observed the resident sitting in a wheelchair wearing dirty, food-stained pants and being taken to the dining room without a clothing change, with the soiled pants not changed until later when two CNAs provided total assistance. Staff, including CNAs, an LN, and an administrative nurse, acknowledged that the resident needed total help with dressing and should always be in clean clothing, revealing a failure to provide appropriate ADL support and maintain clean attire.
A resident with dementia and severe cognitive impairment was transported multiple times in a wheelchair without staff ensuring that his feet remained safely on the foot pedals. Although assessments inaccurately documented that he was independent with walking using a walker and/or wheelchair, his care plan did not instruct staff on proper use of wheelchair foot pedals. During observed transports by CNAs, the resident’s shoed feet repeatedly fell off the pedals and skimmed the floor between them. Staff acknowledged that his feet did not stay on the pedals and that the pedals were not effectively adjusted, and nursing leadership confirmed expectations that feet should remain on the pedals during transport. No wheelchair safety policy was provided.
Unsanitary Kitchen Conditions and Lack of Cleaning Policy
Penalty
Summary
The facility failed to prepare and serve food under sanitary conditions when surveyors observed multiple cleanliness and equipment issues in the kitchen. During an initial kitchen tour on 04/27/26 at 08:57 AM, the three-door reach-in freezer was found with food debris on the bottom shelf, and the three-door reach-in refrigerator had an unknown spilled liquid on the bottom shelf. The drain to the ice machine did not have the required two-inch air gap. Two black two-tiered plastic carts used to store clean dishes had food debris on the bottom tier, and the bottom shelf of the steamtable, which was used to store plate covers, had a buildup of food debris. On 04/28/26 at 01:57 PM, a dietary staff member confirmed these areas required cleaning, and it was identified that the facility did not have a cleaning schedule or a policy regarding kitchen cleanliness. No specific residents, medical histories, or clinical conditions were mentioned in the report in relation to this deficiency.
Failure to Complete and Analyze Care Area Assessments for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to complete comprehensive Care Area Assessments (CAAs) with analysis of underlying causes, contributing factors, and risk factors for multiple residents following MDS assessments. Record review showed that numerous residents had Admission, Annual, or Significant Change MDS assessments that triggered CAAs in areas such as mood/behavior, cognitive loss/dementia, functional abilities, communication, urinary incontinence/indwelling catheter, nutritional status, dental care, pressure ulcers, pain, falls, psychotropic drug use, psychosocial well-being, visual function, and psychosocial well-being. For each of these triggered areas, the corresponding CAAs lacked analysis of the findings. This pattern was identified for residents with a wide range of clinical issues, including dementia, incontinence, falls, pressure ulcers, nutritional concerns, psychotropic medication use, pain, and functional decline. During an interview, a licensed nurse reported that she had stopped writing CAA notes the previous year after being told to do so by someone she could not identify. She stated that she did not write anything on the triggered CAAs and that, at times, she would document risk concerns only on a main check-off worksheet, relying on the fact that the triggers were already reflected in the MDS CAA section. The facility did not provide a policy regarding CAAs when requested. These findings demonstrate that the facility did not ensure that comprehensive assessments were fully completed as required when residents were first admitted and periodically thereafter.
Failure to Maintain Dignity and Privacy for Resident with Indwelling Catheter
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s right to a dignified existence by not maintaining privacy for his urinary catheter drainage bag as directed in his care plan. The resident had diagnoses including bladder calculus and dementia, with a BIMS score of one indicating severe cognitive impairment, and was dependent on staff for toileting hygiene with an indwelling urinary catheter and constant urinary incontinence. His care plan, revised 03/23/26, instructed staff to cover his drainage bag with a privacy cover. However, during observations on 04/27/26, the resident was seen sitting in his wheelchair at his room doorway and later in the dining room with his catheter drainage bag resting on his lower left leg, supported by his shoe, containing dark amber urine and visible to visitors and other residents, without a privacy cover. Staff interviews confirmed that the catheter drainage bag frequently slid from the resident’s left thigh down to his lower leg and that staff did not consistently reposition it or use dignity/privacy bags. One CNA stated he had never placed a dignity bag on the resident’s drainage bag, and another CNA reported that staff on their hall did not utilize catheter dignity bags, instead just moving the bag back up when it slid down. An administrative nurse acknowledged she had not considered staff use of dignity bags for urinary catheters on the memory care unit. The facility’s Resident Rights policy, approved 12/2024, stated that each resident has the right to a dignified existence including privacy and confidentiality, which was not followed in this case.
Failure to Involve Cognitively Able Residents in Care Plan Meetings
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were given the opportunity to participate in the development and implementation of their person-centered plans of care. For one resident with a Brief Interview of Mental Status (BIMS) score of 12, indicating moderately impaired cognition, the electronic medical record showed an admission MDS and a Significant Change MDS, but there was no documentation of any care plan meeting in the prior four months. This resident reported not being invited to any care plan meeting. For a second resident with a BIMS score of 14, indicating intact cognition, the electronic medical record contained an admission MDS and a Quarterly MDS, but there was no documentation of a care plan meeting in the prior two months. This resident also reported not being invited to any care plan meeting. Administrative staff reported that residents and/or family members were supposed to be mailed or hand-delivered invitations to attend care planning meetings and that a copy of the invitation should be uploaded into the EMR. They further stated that an Interdisciplinary Care Conference assessment should be completed in the EMR during the care plan meeting. However, the administrative nurse confirmed that there was no documentation of invitations, Interdisciplinary Care Conference assessments, or completed care plan meetings for the two residents. The facility’s care planning policy stated that social services should attend care plan meetings and that the team presents information to the resident and/or representative about progress toward care plan goals, and referenced federal law requiring resident and/or representative participation in care plan meetings to the extent possible, but this process was not carried out or documented for the two residents identified.
Failure to Keep Call Light Within Reach for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s call light was within reach and to reasonably accommodate the resident’s needs and preferences. The resident had documented diagnoses of C-diff and CHF, and her baseline care plan dated 04/23/26 directed staff to evaluate for changes in level of consciousness but did not include any direction regarding call light use or accessibility. On 04/28/26 at 08:06 AM, surveyors observed the resident’s room door closed while she yelled loudly for help several times. When a licensed nurse entered the room, the resident was lying on her left side in bed, stated she wanted to get up, and reported she could not find her call light. The call light was observed on the floor under her bed. Later that morning, a CNA attached the call light to the resident’s shirt using a black and silver binder clip because the call light cord did not have its own clip. On 04/29/26 at 12:15 PM, the resident was seated in a recliner with the call light again lying on the floor out of her reach; she reported she wanted to go to bed and could not get herself back into bed. Staff interviews revealed that the CNA used the binder clip to keep the call light attached to the resident, and the licensed nurse stated staff should make sure the call light is clipped to the resident’s clothes and reported that the resident would throw her call light on the floor. An administrative nurse stated she expected staff to ensure all residents always have their call lights in reach and was unsure about using a binder clip to hold a call light in place. The facility did not provide a policy regarding call lights.
Failure to Maintain Safe and Sanitary Resident Bathroom Environment
Penalty
Summary
Surveyors identified that the facility failed to maintain a safe, functional, sanitary, and comfortable environment in Resident 87’s bathroom and handwashing area. During an environmental tour with Maintenance Staff UU, surveyors observed an approximately four-foot section of loose baseboard to the left of and behind the toilet, with a black substance present on the wall and floor behind the loose baseboard. They also noted an approximately three-inch crack in the toilet seat and an empty hand soap dispenser hanging above the handwashing sink, mounted with exposed lag bolt fasteners. Maintenance Staff UU confirmed these conditions, acknowledged that the soap dispenser did not work, and stated that the toilet seat should be replaced, the bathroom baseboard removed, the black substance tested for mold, and the sheetrock removed and replaced. Further interview with Maintenance Staff UU revealed that the facility had implemented a QR code system for staff and visitors to report maintenance items, but the issues in this resident’s bathroom had not been reported through that system. He also reported that there had been a leak behind the handwashing sink that had flowed into the bathroom area, leading to the sink’s replacement, but he had received no report of the specific deficiencies observed in the bathroom. Additionally, Maintenance Staff UU stated that the facility did not have policies for maintenance repair in residents’ rooms, and the facility did not provide a policy for ensuring a safe, homelike environment.
Inaccurate MDS Coding for ADLs, Restraints, Falls, and Hospice Services
Penalty
Summary
The deficiency involves the facility’s failure to complete accurate Minimum Data Set (MDS) assessments in accordance with the Resident Assessment Instrument (RAI) User’s Manual, resulting in multiple residents’ clinical status not being correctly reflected. For one resident with dementia and severe cognitive impairment, the Significant Change and subsequent Quarterly MDS assessments coded him as always incontinent of bladder and independent with eating and upper body dressing, with use of a walker and wheelchair. However, the electronic medical record showed ongoing indwelling catheter care each shift and no documentation of walker use, wheelchair mobility, or dressing requirements during the review period. Staff interviews revealed that this resident had an indwelling catheter for more than a year, had not walked for several years, and was dependent on staff for all ADLs, including dressing and wheelchair positioning, contradicting the MDS coding. Observations showed the resident slumped in a wheelchair, wearing a hospital gown over clothing, with a visible catheter bag on his lower leg and feet frequently skimming the floor despite foot pedals being present, further indicating dependence and catheter use not accurately captured on the MDS. Another deficiency involved a resident with a history of stroke, hemiplegia, and hemiparesis whose Significant Change MDS coded the use of “other restraint.” During observation, the resident was seen in bed with bilateral grab bars at the head of the bed and her right arm positioned on a pillow. The resident reported using the grab bars to help move and reposition herself in bed. CNAs and administrative nursing staff confirmed that the facility did not use restraints and that the grab bars were used as enablers to assist residents with repositioning and to increase independence. Administrative staff acknowledged that the MDS coding for restraints was inaccurate because the grab bars did not limit the resident’s voluntary movement or access to her body. A further inaccuracy was identified for a resident with diabetes, atrial fibrillation, unsteadiness of feet, and a toe fracture. Both a Significant Change and a Quarterly MDS documented intact cognition, partial/moderate assistance with transfers, no ambulation, and no falls. However, progress notes in the EMR documented two unwitnessed falls during the look-back period, including one where the resident was found on the floor next to the bed with a forehead skin tear and another where the resident was found sitting on a fall mat on the floor with a scratch on the ankle. These documented falls were not reflected on the MDS. In addition, another resident with diabetes, depression, CAD, and chronic kidney disease had a Significant Change MDS that coded no hospice services, while the EMR contained a hospice certification and physician orders initiating hospice services, and social service notes and staff interviews confirmed that hospice services, including bathing by a hospice aide, were being provided during the look-back period. The consultant MDS nurse confirmed that these assessments were inaccurate and not completed in accordance with the RAI User’s Manual, constituting significant errors in coding for urinary status, ADL dependence, restraints, falls, and hospice services. The consultant MDS nurse stated that the resident with the indwelling catheter should have been coded as not rated for urinary continence due to catheter placement rather than as always incontinent, and that his ADL status should not have been coded as independent given his dependence on staff for dressing and wheelchair positioning. For the resident with grab bars, the nurse confirmed that the grab bars were used as enablers and not as restraints, making the restraint coding inaccurate. For the resident with documented falls, the MDS failed to capture falls that occurred within the look-back period, and for the resident receiving hospice services, the MDS did not reflect hospice care that was active during the look-back period. These miscodings met the RAI Manual’s definition of significant error, in which the resident’s overall clinical status is not accurately represented on the assessment and the error has not been corrected by a more recent assessment.
Failure to Provide and Communicate Baseline Care Plan to New Admission
Penalty
Summary
The deficiency involves the facility’s failure to provide a summary of the baseline care plan to a newly admitted resident and to ensure that the baseline care plan process was completed and documented as required. The resident’s EMR documented diagnoses of C. difficile and CHF. The Entry MDS was completed on the admission date, and the admission MDS was noted as in progress with no information available. A baseline care plan dated the day after admission documented contact precautions, including staff use of gowns and masks when changing contaminated linens and proper handling and bagging of soiled linens. However, during an interview several days after admission, the resident reported she did not know what a baseline care plan was, indicating that the plan had not been explained or summarized to her. Further observations and interviews showed additional failures in implementing and communicating the baseline care plan. On one occasion, the resident was heard yelling for help with her room door closed; when a nurse entered, the resident stated she wanted to get up but could not find her call light, which was observed on the floor under the bed. A nurse reported that the baseline care plan was started on the day of admission and that nurses would review it with the resident, but also stated that the charge nurse would not provide a written copy of the baseline care plan to the resident or family. An administrative nurse reported she would review the baseline care plan with the resident and/or family and claimed to have completed a 48-hour interdisciplinary care conference, but there was no opened or completed conference note in the EMR. She gave inconsistent explanations regarding who was responsible and why the conference note was missing. The facility did not provide a policy for baseline care plans.
Failure to Provide Accurate ADL Assessment and Timely Clothing Changes
Penalty
Summary
The facility failed to provide appropriate assistance with activities of daily living (ADLs), specifically dressing and clothing changes, for a resident with severe cognitive impairment. The resident had a diagnosis of dementia and repeated Brief Interview for Mental Status (BIMS) scores of one, indicating severe cognitive impairment. Despite this, both a Significant Change MDS and a Quarterly MDS inaccurately documented that the resident required only setup assistance with lower body dressing. The ADL Care Area Assessment did not trigger, and the resident’s care plan, revised on 03/23/26, inaccurately instructed staff that the resident was independent with dressing. The electronic medical record lacked staff documentation of the resident’s ADL needs, resulting in care instructions that did not reflect the resident’s actual functional status. On the day of observation, the resident was seen sitting in a wheelchair wearing black pants with food crumbs on them in the morning, and later was transported by a CNA to the dining room still wearing the same dirty pants. The pants were not changed until early afternoon, at which time two CNAs provided total assistance to change the dirty pants, and the resident was unable to participate in dressing or undressing. During interviews, the CNAs, a licensed nurse, and an administrative nurse all stated that residents should always be dressed in clean clothing and confirmed that this resident required total staff assistance with dressing. These observations and interviews showed that the resident’s actual need for total assistance with dressing and clothing changes was not accurately reflected in the MDS, care plan, or ADL documentation, and that the facility did not ensure the resident was kept in clean clothing as expected by facility policy for ADL care.
Failure to Maintain Safe Wheelchair Foot Positioning During Resident Transport
Penalty
Summary
The deficiency involves the facility’s failure to ensure an environment free from accident hazards and to provide adequate supervision during wheelchair transport for a resident with dementia. The resident’s EMR documented a diagnosis of dementia and a BIMS score of one on both a Significant Change MDS and a Quarterly MDS, indicating severe cognitive impairment. These MDS assessments inaccurately documented that the resident was independent with walking using a walker and/or wheelchair, and the ADL CAA did not trigger. The resident’s care plan, revised 03/23/26, identified cognitive impairment due to dementia but did not include instructions for staff on the use of wheelchair foot pedals while propelling the resident. On multiple observed occasions, staff propelled the resident in a wheelchair without maintaining his feet safely on the foot pedals. During transport from his room to the dining room, the resident’s left shoed foot fell from the foot pedal and skimmed the floor between the pedals, and later, during transport from the dining room to the shower room, both shoed feet skimmed the floor between the pedals. CNAs reported that the resident’s feet never stayed on the foot pedals and described the pedals as useless because he could not keep his feet on them. A licensed nurse confirmed the resident’s feet did not always remain on the foot pedals when staff propelled him and stated the pedals should be adjusted to better fit his needs. An administrative nurse stated it was the expectation that staff ensure the resident’s feet remained on the foot pedals during transport and that pedals should be lowered if needed. The facility did not provide a policy regarding wheelchair safety.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
